Fig. 5.

Illustrative case of a failure after a combined approach, which was re-treated using the same approach. A 37-year-old woman presented with minimal hearing loss (Gardner–Robertson class 1) and secondary intractable trigeminal neuralgia. T1-weighted gadolinium-enhanced MR axial images showed a large VS with significant brainstem compression that had a preoperative tumor volume of 11.3 cm³ (upper image left); the tumor volume was reduced to 4 cm³ following the surgery and at the time of the first GKRS (upper image right); the trigeminal neuralgia disappeared and the patient retained functional hearing (Gardner–Robertson class 1). The tumor continued to grow and at 2 years after GKRS, the patient developed recurrent trigeminal neuralgia and gait instability; the MRI showed that the tumor volume had continued to increase to 6.9 cm³ (lower left) and a second surgical resection was decided upon. The tumor volume was reduced to 2.5 cm³ following the second surgery and at the time of the second GKRS (lower right). She remains asymptomatic, with normal facial nerve (House–Brackmann I) and hearing function (Gardner–Robertson 1) following the two surgeries and the two GKRS procedures