Role of Imaging in the Diagnosis and Management of Patients with Vestibular Schwannomas

Publication Date: February 1, 2018


Initial Preoperative Evaluation

Imaging used to detect vestibular schwannomas should use high-resolution T2-weighted and contrast-enhanced T1-weighted MRI. (Level III)
Standard T1, T2, fluid attenuated inversion recovery, and diffusion weighted imaging MR sequences obtained in axial, coronal, and sagittal plane may be used for detection of vestibular schwannomas. (Level III)

Preoperative Surveillance

Preoperative surveillance for growth of a vestibular schwannoma should be followed with either contrast-enhanced 3-dimensional (3-D) T1 magnetization prepared rapid acquisition gradient echo (MPRAGE) or high-resolution T2 (including constructive interference in steady state [CISS] or fast imaging employing steady-state acquisition [FIESTA] sequences) MRI. (Level III)

Postoperative Evaluation

Postoperative evaluation should be performed with postcontrast 3-D T1 MPRAGE, with nodular enhancement considered suspicious for recurrence. (Level II)

Advanced imaging

T2-weighted MRI may be used to augment visualization of the facial nerve course as part of preoperative evaluation. (Level III)

Imaging frequency

MRIs should be obtained annually for 5 yr, with interval lengthening thereafter with tumor stability. (Level III)


Adults with cystic vestibular schwannomas should be counseled that their tumors may more often be associated with rapid growth, lower rates of complete resection, and facial nerve outcomes that may be inferior in the immediate postoperative period but similar to noncystic schwannomas over time. (Level III)

Extent of lateral internal auditory canal involvement

The degree of lateral internal auditory canal involvement by tumor adversely affects facial nerve and hearing outcomes and should be emphasized when interpreting imaging for preoperative planning. ()

Imaging neurofibromatosis type 2

In general, vestibular schwannomas associated with NF2 should be imaged (similar to sporadic schwannomas) with the following caveats: 1. More frequent imaging may be adopted in NF2 patients because of a more variable growth rate for vestibular schwannomas, and annual imagingmay ensue once the growthrate is established. 2. In NF2 patients with bilateral vestibular schwannomas, growth rate of a vestibular schwannoma may increase after resection of the contralateral tumor, and therefore, more frequent imaging may be indicated, based on the nonoperated tumor’s historical rate of growth. 3. Careful consideration should be given to whether contrast is necessary in followup studies or if high-resolution T2 (including CISS or FIESTA-type sequences) MRI may adequately characterize changes in lesion size instead. (Level III)

Duration of follow-up

For patients receiving gross total resection, a postoperative MRI may be considered to document the surgical impression and may occur as late as 1 yr after surgery. For patients not receiving gross total resection, more frequent surveillance scans are suggested; annual MRI scans may be reasonable for 5 yr. Imaging followup should be adjusted accordingly for continued surveillance if any change in nodular enhancement is demonstrated. (Level III)

Recommendation Grading




Role of Imaging in the Diagnosis and Management of Patients with Vestibular Schwannomas

Authoring Organization

Publication Month/Year

February 1, 2018

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Social worker, physician, nurse, nurse practitioner, physician assistant


Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D015837 - Vestibular Diseases, D005154 - Facial Nerve


magnetic resonance imaging (MRI), facial nerve, vestibular schwannomas, acoustic neuroma, Advanced imaging, Cystic, growth rate, Intracranial nerve

Supplemental Methodology Resources

Systematic Review Document


Number of Source Documents
Literature Search Start Date
January 1, 1990
Literature Search End Date
December 31, 2014