The surgical management of vestibular schwannomas should be based on their presentation, neuro-imaging findings, surgeons' expertise, and logistics. Multi-stage surgery can be beneficial for large-sized lesions with acute presentations. Herein, we highlighted the indications for two cases managed initially through the retrosigmoid and, subsequently, translabyrinthine approaches. The first case presented with acute balance and gait issues and a long history of hearing loss and blurred vision. Neuroimaging findings revealed a cerebellopontine angle lesion, resembling a vestibular schwannoma, with significant brainstem compression and hydrocephalus. Due to the rapidly deteriorating clinical status and large-sized tumor, we first proceeded with urgent decompression via a retrosigmoid approach, followed by gross total resection via a translabyrinthine approach two weeks later. The second case presented with gradually worsening dizziness and hemifacial numbness accompanied by acute onset severe headaches and hearing loss. Neuroimaging findings showed a large cerebellopontine angle lesion suggestive of a vestibular schwannoma with acute intratumoral hemorrhage. Given the acute clinical deterioration and large size of the tumor, we performed urgent decompression with a retrosigmoid approach followed by gross total resection through a translabyrinthine approach a week later. Post-surgery, both patients showed excellent recovery. When managing acutely presented large-sized vestibular schwannomas, immediate surgical decompression is vital to avoid permanent neurological deficits.
Keywords: facial nerve; nervus intermedius; retrosigmoid approach; staged surgery; translabyrinthine approach; vestibular schwannoma.