Acute presentation of giant sporadic vestibular schwannoma with massive hemorrhage: A critical review with a case illustration

Hemorrhage in vestibular schwannoma (VS) is a rare but potentially devastating complication, owing to the proximity to the brainstem and small space in the posterior fossa. it is a challenge to manage such patients, coming in emergency in comatose state and whether early intervention can reverse the consequence or not. A 42-year-old male presented in emergency room (ER) with sudden onset of severe headache followed by loss of consciousness, with GCS- 3 (E1V1M1) and mid-dilated fixed pupil. Computer tomography (CT scan) head revealed a large hematoma in the right cerebellopontine angle (CP) with hydrocephalus, requiring urgent CSF diversion (External Ventricular Drain) in the ER. Subsequently microsurgical excision of the tumor was done after few days, once patient has shown improvement in GCS. Histopathology confirmed it as hemorrhagic VS. Post-operatively, he had right HB (House- Brackemann) grade IV facial weakness which could not be appreciated in preoperative phase. He gradually recovered well and was able to walk without support at the time of discharge. At 4 months follow up, facial weakness slightly improved to HB grade III, and patient was doing his daily activity without difficulty. Follow-up magnetic resonance imaging (MRI) imaging showed a small residue near internal acoustic meatus (IAM). Hemorrhage in VS is associated with increased morbidity and mortality; and few times, urgent intervention can save life despite of comatose state of the patient. •Vestibular schwannoma with bleed is a rare phenomenon.•These tumors becomes very challenging to manage because of significant increase in size causing brainstem compression and herniation.•Urgent Cerebrospinal fluid (CSF) diversion in patients with Glasgow coma scale (GCS) score-3 can also revive the patient if attempted early.