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Vestibular Schwannoma (VS), previously known as acoustic neuroma, constitutes the majority of tumours found in the cerebellopontine angle (CPA). Most guidelines for managing CPA tumours have been developed by high-income countries (HICs). However, these guidelines often fall short in addressing the unique challenges encountered in low- and middle-income countries (LMICs), such as Pakistan. In LMICs, issues related to a limited healthcare workforce, inadequate infrastructure, and constrained financial resources hinder the effective implementation of these HIC-derived guidelines. Additionally, it has been observed that VS tends to present at a larger size in LMICs compared to HICs. Given that VS is the predominant type of CPA tumour and other types are covered under separate guidelines, this article aims to provide practical, contextspecific recommendations for the screening, diagnosis, and management of Vestibular Schwannoma in LMIC settings. Our focus is to bridge the gap in care strategies and adapt them to the resource constraints and clinical realities of LMICs.

Objective: To review the demographic trends clinical spectrum, diagnosis, management and out come of patients with vestibular Schwannoma and to identify areas where improvements are needed., Methods: All patients with vestibular schwannoma admitted to the Aga Khan University Hospital over the past 11 years were reviewed retrospectively., Results: The age range of majority of 22 patients analyzed, was 41-50 years (23%). Hearing loss was the most common presenting symptom (96%). Other clinical features included cranial nerve palsies (59%) and headache (55%). Fifty percent had signs of raised intracranial pressure. Neuroimaging revealed "Stage IV b" (tumor distorting the brainstem and compressing the 4th ventricle) in 50% cases. Neurosurgical intervention was carried out in 86%; mainly using the retrosigmoid approach. Postoperative complications included facial nerve palsy in 13 (65%) and hydrocephalus in 5 (25%) patients. Hearing determined clinically was preserved in three patients (14%). One patient died during the inpatient stay., Conclusion: Presentation of these patients is late and the outcome is poor.