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P518: A PREDICTIVE ANALYSIS OF THE CLINICAL AND SOCIAL DRIVERS OF EMERGENT PRESENTATION IN VESTIBULAR SCHWANNOMA MANAGEMENT
Stephanie M Younan, MPH, BS; Lourdes Kaufman, BA; Rithvik Ramesh, BA; Ruben Hernandez, BS; Nadeem Al-Adli, MD; Philip V Theodosopoulos, MD; Steven W Cheung, MD; Ramin Morshed, MD; Nicole T Jiam, MD; UCSF

Background: Vestibular schwannomas (VS) are typically managed through non-emergent referral pathways. However, a subset of patients presents emergently through the emergency department (ED), and the clinical, pathological, and socioeconomic factors distinguishing these cohorts are poorly defined. This study aimed to comprehensively characterize the differences in tumor biology, sociodemographic factors, and perioperative outcomes between patients undergoing VS surgery via emergent versus non-emergent referral.

Methods: Patients who underwent vestibular schwannoma resection at a large urban tertiary care center between 2010 and 2024 were retrospectively identified. Patients were stratified by referral pathway: Emergency Department (ED; n=48) versus Non-Emergency (Non-ED; n=260). Demographic, clinical, and outcome variables were compared using Student’s t-test, Mann-Whitney U, and chi-square tests. A multivariate logistic regression model was then developed to identify independent predictors of ED referral, with results reported as adjusted odds ratios (aOR).

Results: The ED cohort presented with symptoms of acute neurological compromise, most commonly related to hydrocephalus and brainstem compression, whereas the non-ED cohort typically presented with indolent otologic symptoms This was reflective of a significantly greater tumor burden in the ED cohort, including larger median tumor volumes (17.3 cm³ vs. 6.3 cm³, p<0.001) and a markedly increased incidence of pretreatment hydrocephalus (60.4% vs. 13.1%, p<0.001). Significant SDoH disparities were observed; ED patients were more frequently of Hispanic/Latino ethnicity (29.2% vs. 9.2%, p<0.001), were more likely to be non-English speaking (20.8% vs. 6.9%, p=0.005), and had higher rates of Medicaid insurance (41.7% vs. 20.4%, p=0.003). Postoperatively, ED patients had lower rates of gross total resection (8.3% vs. 23.1%, p=0.020) and experienced a substantially longer median hospital stay (10.5 vs. 3.0 days, p<0.001). Long-term tumor control, however, was comparable between the cohorts, with no significant difference in recurrence rates (14.3% vs. 12.5%, p=0.699). On multivariate analysis, the strongest independent predictors of ED referral were pretreatment hydrocephalus (aOR 3.73, 95% CI 2.66-5.25), larger tumor volume (aOR 1.82, 95% CI 1.57-2.12), non-English language (aOR 1.96, 95% CI 1.22-3.13), Hispanic/Latino ethnicity (aOR 1.82, 95% CI 1.22-2.71), and a higher Charlson Comorbidity Index (aOR 1.33, 95% CI 1.10-1.60).

Conclusion: Emergent presentation for VS surgery represents a distinct clinical phenotype driven by an independent combination of advanced anatomical tumor stage, medical comorbidity, and social vulnerability. While surgical teams achieve comparable long-term tumor control, the emergent pathway is associated with a substantially increased burden of care and resource utilization. These findings highlight a critical intersection of compressive tumor pathophysiology and healthcare disparity, suggesting that barriers to routine care for vulnerable populations may delay diagnosis until the onset of acute neurological decompensation.

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