Vestibular schwannoma with hemorrhage in a 63-year-old female: A case report.

Vestibular schwannomas are benign cranial nerve tumors that typically follow an indolent course. Management strategies are guided by tumor size, growth rate, and neurological compression. However, a small proportion show aggressive behavior characterized by rapid expansion, cystic degeneration, or spontaneous intratumoral hemorrhage, resulting in acute neurological deterioration. We report a 63-year-old woman presenting with progressive cerebellar symptoms and lower cranial nerve dysfunction. Neuroimaging revealed a giant Koos grade IV cystic vestibular schwannoma with intratumoral hemorrhage causing significant brainstem compression. Subtotal microsurgical resection via a retrosigmoid approach achieved brainstem decompression while preserving facial nerve continuity, followed by adjuvant fractionated stereotactic radiotherapy targeting residual disease. This approach resulted in complete neurological recovery, including full restoration of facial nerve function (House-Brackmann grade I) and tumor stability at 8-month follow-up. Giant Koos grade IV vestibular schwannomas with combined cystic and hemorrhagic features are exceptionally rare and pose unique management challenges. Our results support a customized, function-first combined-modality strategy that prioritizes functional outcomes over gross-total resection in pathologically complex but histologically benign tumors.