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Purpose <p>Facial nerve (FN) preservation in vestibular schwannoma (VS) remains challenging, and outcomes in cystic VS are inconsistent. This study aimed to identify cyst-specific imaging features defining a high-risk subset predictive of postoperative FN dysfunction.</p> Methods <p>A retrospective cohort of patients who underwent VS resection (2002–2024) was analyzed. Morphological characteristics of the cystic components on preoperative magnetic resonance imaging were classified as central or peripheral types, with peripheral cysts subclassified by anatomical direction. Logistic regression identified predictors of poor FN outcome (House–Brackmann [HB] grade ≥ III).</p> Results <p>Of 266 patients, 77 (29.8%) had cystic VS. Among these, 18.2% were central type and 81.8% peripheral type; anterior, medial, and posterior components were present in 51.9%, 68.8%, and 62.3%, respectively. Poor short-term FN outcomes occurred in 19 patients (24.7%) and were associated with absence of the fundal fluid cap (FFC) sign (63.2% vs. 25.9%, <i>p</i> = 0.005), anterior cerebellopontine angle (CPA) subtype (84.2% vs. 31.0%, <i>p</i> &lt; 0.001), anterior peripheral cysts (73.7% vs. 44.8%, <i>p</i> = 0.036), and internal auditory canal cyst extension (15.8% vs. 1.7%, <i>p</i> = 0.044). Extent of resection did not differ between outcome groups. Multivariate analysis identified absence of the FFC sign (OR 8.75), anterior CPA subtype (OR 21.9), and anterior peripheral cysts (OR 6.92) as independent predictors of poor FN outcome. A risk stratification integrating these features demonstrated excellent discrimination (AUC 0.853). High-risk patients experienced significantly worse short- and long-term FN outcomes (preservation rates of good FN function [HB grade I–II]: 40.7% vs. 94.0%, <i>p</i> &lt; 0.001; 81.5% vs. 96.0% at 12 months, <i>p</i> = 0.048).</p> Conclusions <p>Anterior peripheral cyst morphology, together with absence of the FFC sign and anterior CPA subtype, defines a high-risk subset of cystic VS strongly associated with unfavorable FN outcomes, supporting improved preoperative risk stratification.</p>

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High-risk morphology in cystic vestibular schwannomas: an imaging-based scoring system for facial nerve outcomes

  • 期刊论文

  • 发表日期：

    2026年1月26日

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  • Yuichi Fujita,
  • Yoichi Uozumi,
  • Yosuke Fujimoto,
  • Hiroaki Nagashima,
  • Masaaki Kohta,
  • Kazuhiro Tanaka,
  • Hidehito Kimura,
  • Eiji Kohmura,
  • Takashi Sasayama

摘要

Purpose

Facial nerve (FN) preservation in vestibular schwannoma (VS) remains challenging, and outcomes in cystic VS are inconsistent. This study aimed to identify cyst-specific imaging features defining a high-risk subset predictive of postoperative FN dysfunction.

Methods

A retrospective cohort of patients who underwent VS resection (2002–2024) was analyzed. Morphological characteristics of the cystic components on preoperative magnetic resonance imaging were classified as central or peripheral types, with peripheral cysts subclassified by anatomical direction. Logistic regression identified predictors of poor FN outcome (House–Brackmann [HB] grade ≥ III).

Results

Of 266 patients, 77 (29.8%) had cystic VS. Among these, 18.2% were central type and 81.8% peripheral type; anterior, medial, and posterior components were present in 51.9%, 68.8%, and 62.3%, respectively. Poor short-term FN outcomes occurred in 19 patients (24.7%) and were associated with absence of the fundal fluid cap (FFC) sign (63.2% vs. 25.9%, p = 0.005), anterior cerebellopontine angle (CPA) subtype (84.2% vs. 31.0%, p < 0.001), anterior peripheral cysts (73.7% vs. 44.8%, p = 0.036), and internal auditory canal cyst extension (15.8% vs. 1.7%, p = 0.044). Extent of resection did not differ between outcome groups. Multivariate analysis identified absence of the FFC sign (OR 8.75), anterior CPA subtype (OR 21.9), and anterior peripheral cysts (OR 6.92) as independent predictors of poor FN outcome. A risk stratification integrating these features demonstrated excellent discrimination (AUC 0.853). High-risk patients experienced significantly worse short- and long-term FN outcomes (preservation rates of good FN function [HB grade I–II]: 40.7% vs. 94.0%, p < 0.001; 81.5% vs. 96.0% at 12 months, p = 0.048).

Conclusions

Anterior peripheral cyst morphology, together with absence of the FFC sign and anterior CPA subtype, defines a high-risk subset of cystic VS strongly associated with unfavorable FN outcomes, supporting improved preoperative risk stratification.