What Radiomics Teaches Us About Vestibular Schwannoma Biology: Imaging Biomarkers, Artificial Intelligence, and Future Clinical Translation: A Narrative Review

Background/Objective: Vestibular schwannoma is a benign Schwann cell tumor characterized by marked biological and clinical heterogeneity, resulting in highly variable growth patterns, hearing outcomes and treatment responses. Advances in molecular biology have improved the understanding of the pathways driving tumor development, highlighting the roles of NF2-related signaling, angiogenesis, inflammation and tumor-microenvironment interactions. In parallel, quantitative imaging, radiomics, and artificial intelligence (AI) are being investigated for tumor characterization and outcome prediction, although the biological specificity of many imaging-derived features remains unproven. Methods: This narrative review was conducted by examining recent literature on the role of radiomics in Vestibular schwannoma biology. Results: Across published studies reviewed we summarize the current knowledge on vestibular schwannoma biology and discusses the clinical potential of quantitative MRI, volumetric analysis, radiomics and AI for tumor characterization, growth prediction, treatment-response assessment, automated segmentation and functional outcome prediction. Conclusions: Particular emphasis is placed on distinguishing reported predictive associations from validated biological correlates and on the potential value of integrating imaging with molecular data. Finally, current limitations, including methodological heterogeneity, lack of standardization and the need for multicenter validation, are discussed to outline future directions for clinical translation.