Prevention Of Cerebrospinal Fluid Leakage Research Articles

Reconstruction of Scalp and Skull Defects by a Free Anterolateral Thigh Flap Combined With Fascia Lata and Vastus Lateralis Muscle.

Reconstruction of composite scalp and skull defects is a great challenge for plastic surgeons, and this study aimed to report the therapeutic regimen of using free ALT flaps with fascia lata and vastus lateralis muscle to cover scalp and cranial defects. A retrospective analysis was performed including 10 patients with composite scalp and skull defects who were treated with a free ALT flap with fascia lata and vastus lateralis muscle from January 2012 to June 2020. All patients underwent a 1-stage operation and were followed up for 1 year with clinical data including sex, age, etiology, skull defect area, scalp defect area, flap area, dura mater involvement, recipient vessel, donor site repair, lumbar cistern drainage, and complications. All flaps survived well, 2 patients developed complications, one had cerebrospinal fluid leakage, and another experienced partial skin graft necrosis; All patients were satisfied with both the appearance and functional outcomes of the procedure. Free tissue transplantation is an effective method for large defects of the scalp and skull. The combination of a free ALT flap with fascia lata and vastus lateralis muscle, which has a long pedicle, convenient flap designs, less donor-site morbidity, and effective prevention of cerebrospinal fluid leakage, is an ideal choice to repair the composite scalp and cranial defects in stage 1.

Hemopatch® as a primary dural sealant in cranial neurosurgery: Technical note and a retrospective study.

To determine the effectiveness and safety of Hemopatch® as a primary dural sealant in preventing CSF leakage following cranial surgery. Cerebrospinal fluid (CSF) leaks occur in cranial operations and are associated with significant patient burden and expense. The use of Hemopatch® as a dural sealant in cranial neurosurgical procedures is described and analyzed in this study. Data were retrospectively collected from all patients who underwent a craniotomy for various neurosurgical indications where Hemopatch® was used as the primary dural sealant between June 2017 and June 2022. Infection and CSF leak were the main indicators evaluated after surgery. A total of 119 consecutive patients met our inclusion criteria. The median was age 41.5 years, and 52.5% were female. The mean follow-up period was 2.3 years (7 months to 6 years). There were 110 (92.44%) supratentorial and 9 (7.56%) infratentorial craniotomies. Postoperative CSF leak was reported in 2 patients (1.68%), one in each cohort. Postoperative infection occurred in one patient (0.84%). The results suggest that using Hemopatch® as a dural sealant in cranial surgery is effective and safe. After supra-/infratentorial craniotomies, the rate of postoperative adverse events in our sample was within the range of known surgical revision rates. Future randomized clinical studies are required to confirm our encouraging findings.

A low-swelling hydrogel as a multirole sealant for efficient dural defect sealing and prevention of postoperative adhesion

Abstract Dural defects and subsequent complications, including cerebrospinal fluid (CSF) leakage, are common in spine surgery and neurosurgery, and existing clinical treatments are still unsatisfactory. In this study, a tissue-adhesive and low-swelling hydrogel sealant comprising gelatin and o-phthalaldehyde (OPA)-terminated 4-armed poly(ethylene glycol) (4aPEG-OPA) is developed via the OPA/amine condensation reaction. The hydrogel shows an adhesive strength of 79.9 ± 12.0 kPa on porcine casing and a burst pressure of 208.0 ± 38.0 cmH2O. The hydrogel exhibits a low swelling ratio at physiological condition, avoiding nerve compression in the limited spinal and intracranial spaces. In rat and rabbit models of lumbar and cerebral dural defects, the 4aPEG-OPA/gelatin hydrogel achieves excellent performance in dural defect sealing and preventing CSF leakage. Moreover, local inflammation, epidural fibrosis and postoperative adhesion in the defect areas are markedly reduced. Thus, these findings establish the strong potential of the hydrogel sealant for the effective watertight closure of dural defects.

Prevention of Cerebrospinal Fluid Leakage in the Anterior Transpetrosal Approach.

Background: The anterior transpetrosal approach (ATPA) is effective for reaching petroclival lesions, and it allows for complications such as impaired venous return and neuropathy to be resolved. However, there is still room for improvement regarding cerebrospinal fluid (CSF) leakage. Here, we aim to focus on describing specific preoperative, intraoperative, and postoperative countermeasures for preventing CSF leakage when using the ATPA. Methods: Eleven patients treated using the ATPA, who were treated at our hospital from June 2019 to February 2023, were included in this descriptive study. Preoperatively, we performed a 3D simulation of the opened air cells. Then, we classified patterns of dural closure into three types based on intradural manipulation and whether it involved opened air cells or not. Intraoperatively, we performed a dural closure that included the use of more-watertight sutures (DuraGen®) and an endoscope. Furthermore, temporal bone air cell volume measurements were performed to confirm the correlation between the volume and factors related to CSF leakage. Results: No postoperative CSF leakage was observed in any patient. The temporal bone air cell volumes significantly corelated with the air cells of the petrous apex, the high-risk tract in the petrous apex, and postoperative fluid collection in mastoid air cells. Conclusions: We have described countermeasures for preventing CSF leakage when using the ATPA. Preoperative simulations and the use of multiple-layered dural reconstructions with endoscopes could be considered more reliable methods for preventing CSF leakage when using the ATPA.

Incidental Dural Tears During Lumbar Spine Surgery: Prevalence and Evaluation of Management Outcomes.

Incidental dural tears (IDTs) are sometimes observed asan intraoperative complication associated withlumbar spine surgery. Commonly, this complication is recognized and repaired during surgery, but if it is undiagnosed or inadequately treated, a variety of consequences may occur. Many techniques have been developed to treat cerebrospinal fluid (CSF) leakage, and each has its limitations. Objectives: To assess the prevalence of incidental dural tears in lumbar spine surgeries and evaluate the outcomes of the sandwich technique in the management of this complication. A total of 92 patients who underwent lumbar spine surgery at the Royal Rehabilitation Center in Amman from January 2018 to December 2021 were retrospectively reviewed. Patients were divided into two groups: group A (patients without IDT) and group B (patients with IDT), where group B was repaired using the sandwich technique. The follow-up period was six months. Further, the sandwich technique involves repairing the dural defect with interlocking sutures, painting medical glue around the dural incision, covering this with gelatin sponge, and finally covering the gelatin sponge with medical glue again. The overall prevalence of IDT in the study group was 14.1%. IDT was more common among elderly patients above the age of 60 (17.2%), females (16.7%), patients with multiple lumbar levels treated (66.7%), open approaches (21%), and those who had previous spinal surgery (72.7%). Most IDTs were diagnosed and managed intraoperatively (84.6%). Among those patients, only one complained of a surgical site infection. Patients in group B had a significantly higher postoperative length of hospital stay, amount of drainage, and operative time compared to group A (P<0.001). Regarding postoperative pain, patients in group B had significantly higher pain on the Numerical Pain Scale at day three post-operation compared to patients in group A (P<0.001). Based on our results, the sandwich technique was effective in the management and prevention of CSF leakage. Further prospective studies with long-term follow-up are needed to confirm our findings.

미세혈관 감압술에서의 뇌척수액 유출 예방을 위한 경막의 네 겹중첩 봉합

Background: Cerebrospinal fluid (CSF) leakage is one of major complication following cranial surgery. Many studies have been introducing surgical methods to prevent CSF leakage. Technique applying dural substitutes are being studied for its efficacy for preventing CSF leakage. We introduce four layer onlay stacking repair (FLOSR), effective dural closing technique for preventing CSF leak-age, while avoiding application of foreign material intradural space.&#x0D; Materials and Methods: Retrospective analysis of patients undergone microvascular decompres-sion (MVD) surgery for hemifacial spasm (HFS) and trigeminal neuralgia (TN) by a single surgeon in single center between September 2020 and September 2022 was done. MVD was done by retro-mastoid suboccipital approach. Number of patients who had CSF leakage, symptoms occurred by CSF leakage and treatment done for the patients were collected.&#x0D; Results: In this study, 355 patients underwent MVD for HFS and TN and 4 were excluded. Three patients of selected 351 patients who underwent MVD for HFS were suspected for CSF leakage which counts for approximately 0.9% of patients. All patients suspected for CSF leakage underwent MVD for HFS (3 of 3, 100%). Continuous lumbar drainage of 180-240 cc per day for 5 days was done and every patient had symptom improvement.&#x0D; Conclusions: FLOSR provided an effective method intra-operatively in preventing and lowering risk of severe CSF leakage after craniotomy by RMSOC (retromastoid suboccipital craniotomy) ap-proach without the risk of placing foreign materials inside dura.

Anatomy of the Frontal Sinus Drainage Pathway Evaluated in 247 Cadavers to Prevent Cerebrospinal Fluid Leakage After Frontobasal Craniotomy.

The frontal sinus (FS) drainage pathway (FSDP) may be a conduit for cerebrospinal fluid leakage after frontobasal craniotomy. In this cadaveric study, we aimed to evaluate the anatomy of the FSDP. The FSs and FSDPs of 247 cadavers were investigated. We counted the number of FSs and FSDPs in each half-head, verified the presence of a narrowing section in each FSDP, and evaluated the depth, shape, and size of each narrowing FSDP section. We investigated 494 sides and 472 FSDPs of 247 cadavers. FSs were unilaterally undeveloped in 13 of 247 cadavers (5.3%) and bilaterally in 8 (3.2%). FSs were unilaterally duplicated in 7 of 247 cadavers (2.8%), and no FSs were bilaterally duplicated or triplicated. No FSs had 2 or more FSDPs, and all 472 investigated FSDPs were invariably narrowed at various depths. The narrowing FSDP sections were elliptical (78.6%), circular (18.1%), triangular (1.8%), or crescent-shaped (1.4%) and of varying thickness and orientation. Although FSDPs were asymmetric in 92.2% of cadavers and narrowing FSDP sections were located deep (8.9 ± 4.4 mm from the anterior skull base), the narrowing FSDP sections were typically small (area: 5.9 ± 3.3 mm2) or thin (short diameter: 2.1 ± 0.7 mm). Each FS had only one FSDP, all FSDPs were invariably narrowed at various depths, and the narrowing FSDP sections were sufficiently small or thin to allow local closure, facilitating prevention of cerebrospinal fluid leakage after frontobasal craniotomy.

Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons

Cerebrospinal fluid (CSF) leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique. Injectable hydroxyapatite (HXA) has shown promising results to prevent CSF leakage. This study aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group (0% vs. 26.3%, p = 0.016). No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons.

Innovations in Combined Surgery of Endoscopic Transsphenoidal Surgery and Craniotomy

Combined endoscopic transsphenoidal surgery and craniotomy may be useful for tumors extending into the suprasellar region or ventricles and for tumors extending simultaneously into the nasal sinuses and intracranial space. This method allows two surgeons to share the surgical field while compensating for each other's blind spots and allows for safe tumor removal by separating the normal structure from the tumor and protecting the normal structure. Simultaneous combined endoscopic transsphenoidal surgery and craniotomy require a lot of equipment; however, by devising the layout of the equipment in the operating room, the staff involved in the surgery can perform their roles more effectively. However, this method results in extensive dural and cranial defects, and prevention of cerebrospinal fluid leakage and perioperative surgical site infection is essential. Skull base reconstruction using autologous tissues and medical materials at appropriate locations can reduce the risk of postoperative cerebrospinal fluid leakage and surgical site infection. Furthermore, multilayered reconstruction using restorative medical materials eliminates the need for autologous tissue, is minimally invasive, shortens the operative time, reduces postoperative stress, and shortens the length of hospital stay. A combination of endoscopic transsphenoidal surgery and craniotomy will contribute to the improvement of the safety of highly difficult tumorectomies under a reliable skull base reconstruction method.

Cerebrospinal fluid leakage prevention using the anterior transpetrosal approach with versus without postoperative spinal drainage: an institutional cohort study.

The efficacy of spinal drain (SD) placement for cerebrospinal fluid (CSF) leakage prevention after the anterior transpetrosal approach (ATPA) remains unclear. Thus, we aimed to assess whether postoperative SD placement improved postoperative CSF leakage after a skull base reconstruction procedure using a small abdominal fat and pericranial flap and clarify whether bed rest with postoperative SD placement increased the length of hospital stay. This retrospective cohort study included 48 patients who underwent primary surgery using ATPA between August 2011 and February 2022. All cases underwent SD placement preoperatively. First, we evaluated the necessity of SD placement for CSF leakage prevention by comparing the postoperative routine continuous SD placement period to a period in which the SD was removed immediately after surgery. Second, the effects of different SD placement durations were evaluated to understand the adverse effects of SD placement requiring bed rest. No patient with or without postoperative continuous SD placement developed CSF leakage. The median postoperative time to first ambulation was 3days shorter (P < 0.05), and the length of hospital stay was 7days shorter (P < 0.05) for patients who underwent SD removal immediately after surgery (2 and 12days, respectively) than for those who underwent SD removal on postoperative day 1 (5 and 19days, respectively). This skull base reconstruction technique was effective in preventing CSF leakage in patients undergoing ATPA, and postoperative SD placement was not necessary. Removing the SD immediately after surgery can lead to earlier postoperative ambulation and shorter hospital stay by reducing medical complications and improving functional capacity.

Acetazolamide, Short Bed Rest, and Subfascial Off-Suction Drainage in Preventing Persistent Spinal Fluid Leaks from Incidental Dural Tears.

Postoperative cerebrospinal fluid (CSF) leak might occur after the repair of dural tears. Acetazolamide lowers intradural pressure by decreasing CSF production. The aim of this study was to investigate the incidence of persistent CSF leak from incidental dural tears after using acetazolamide, short bed rest, and subfascial off-suction drainage. The medical records at the Ain Shams University hospital were examined retrospectively for this descriptive single-arm cohort study. Adult patients who underwent lumbar degenerative spine surgery from January 2011 through January 2021 were enrolled. The included patients experienced a CSF leak and were administered acetazolamide 1.5 g/d from postoperative day (POD) 1 to POD 7. Subfascial drainage was kept for a maximum of 5 days without suction. Seventy-four patients met the inclusion criteria of the study. Fifty-nine patients (79.7%) had recurrent lumbar surgery. The average age of the patients was 55.7 years. In all patients, the quantity of fluid in the drain decreased on a daily basis. The subfascial drain was kept for 5 days in 26 patients (35.1%). There was no wound infection, collection, or persistent CSF leakage in any of the patients over the 6-month follow-up period. In this study, acetazolamide was well tolerated by the patients and, in addition to short bed rest (72 hours) and off-suction subfascial drainage, did not result in persistent CSF leakage in any patient. A prospective placebo-controlled study is beneficial to confirm the efficacy of acetazolamide in preventing CSF leakage.

Ex vivo and in vivo evaluation of transsphenoidal Liqoseal application to prevent cerebrospinal fluid leakage

BackgroundDespite improvements in closure techniques by using a vital nasoseptal flap, the use of sealing materials, and improved neurosurgical techniques, cerebrospinal fluid (CSF) leak after transsphenoidal surgery still is a clinically relevant problem. Liqoseal® (Polyganics bv, Groningen, The Netherlands) is a CE-approved bioresorbable sealant patch for use as an adjunct to standard methods of cranial dural closure to prevent CSF leakage. This study aims to evaluate the application of Liqoseal in transsphenoidal surgery ex vivo and in vivo.Methods1. We created an ex vivo setup simulating the sphenoidal anatomy, using a fluid pump and porcine dura positioned on a conus with the anatomical dimensions of the sella to evaluate whether the burst pressure of Liqoseal applied to a bulging surface was above physiological intracranial pressure. Burst pressure was measured with a probe connected to dedicated computer software. Because of the challenging transsphenoidal environment, we tested in 4 groups with varying compression weight and time for the application of Liqoseal. 2. We subsequently describe the application of Liqoseal® in 3 patients during transsphenoidal procedures with intraoperative CSF leakage to prevent postoperative CSF leakage.Results1. Ex vivo: The overall mean burst pressure in the transsphenoidal setup was 231 (± 103) mmHg. There was no significant difference in mean burst pressure between groups based on application weight and time (p = 0.227). 2. In Vivo: None of the patients had a postoperative CSF leak. No nose passage problems were observed. One patient had a postoperative meningitis and ventriculitis, most likely related to preoperative extensive CSF leakage. Postoperative imaging did not show any local infection, swelling, or other device-related adverse effects.ConclusionsWe assess the use of Liqoseal® to seal a dural defect during an endoscopic transsphenoidal procedure as to be likely safe and potentially effective.

The diagnosis of cerebrospinal fluid leakage after microvascular decompression surgery and management via lumbar drain

Objective: In posterior fossa surgery such as microvascular decompression (MVD), cerebrospinal fluid (CSF) leakage is a crucial problem. In this study, we explored the accurate diagnosis and effective non-surgical management of postoperative CSF leakage.Methods: We reviewed 749 patients who underwent MVD surgery from August 2018 to April 2022. Although we significantly reduced the CSF leakage problem by using the triple-layer closing technique (TLCT), CSF leakage was still a problem in a few cases. We managed these patients with the same diagnostic flow and treatment regimen using a lumbar drain (LD).Results: Among the 749 patients in the cohort, 11 (1.4%) had CSF leakage, and each of those cases presented with rhinorrhea. Five patients (45.5%) had the symptom on the first day, two patients (18.2%) on the second day, one patient (9.1%) on the third day, and three patients (27.3%) on the fifth day after surgery. After conservative treatment including CSF drainage via LD for 5.4 days on average, none of the patients had recurrent symptoms suggesting CSF leakage; thus, there was no need for wound repair surgery.Conclusion: Despite diligent attempts to prevent CSF leakage in open microsurgery, leaks inevitably occur in some cases and are more frequent in posterior fossa surgery. Although we cannot fully prevent leakage, we should limit the complication to ensure that it does not progress into other severe problems, such as meningitis. A closing technique such as TLCT is useful, but the early diagnosis and management of CSF leakage with LD is also important.

The Anterior Transpetrosal Approach

The Anterior transpetrosal approach is a skull base surgical procedure that can provide a wide operative view of the petroclival and the prepontine region. This approach requires one to accurately understand the anatomy of the anterior part of the temporal bone and the histological structure of the dura mater. In addition, it is necessary to learn operative techniques for venous preservation, accurate hemostasis at each step, and prevention of cerebrospinal fluid leakage. In this article, the anatomy and surgical techniques that are required for a beginner to master the anterior transpetrosal approach are explained step by step.

Resection of Lumbar Spinal Facet Joint Cysts and Cerebrospinal Fluid Leakage: Incidence, Prognostic Parameters, and Outcome in a Single-center Series.

Single-center series. Intraspinal facet joint cysts can lead to nerve root compression symptoms with severe discomfort and disability. Permanent improvement can be achieved by surgical resection of the cyst. However, cerebrospinal fluid (CSF) leakage is a common problem in resection of facet joint cyst.The aim of the study was to investigate the frequency of CSF leak after resection of a joint cyst and to determine predictive factors. A total of 176 consecutive patients underwent surgery for lumbar spinal facet joint cyst in our institution between 1997 and 2018. Patients with a CSF leak were compared with patients without a CSF leak (control group). CSF leakage occurred in 14 patients (8.0%) In 2 of the cases (14.3%), the CSF leak was recognized only postoperatively, in 12 cases (85.7%), the CSF leak was detected intraoperatively. Despite intraoperative dura repair, 4 of these 12 patients (33.3%) presented with CSF leakage postoperatively. Altogether 6 patients had postoperative CSF leakage. Compared with patients without CSF leak, there were no differences in preoperative symptoms, surgical technique, complications, or postoperative findings. Adhesion of the cyst to the dura mater was present in all 14 patients with CSF leakage (100%), but only 61.7% of the control group ( P <0.005). All patients in the CSF leak group showed an improvement of their preoperative symptoms. The rate of CSF leakage in resection of spinal facet joint cyst was 8% in the present study. The occurrence of a CSF leakage was independent of clinical factors, level, or side of the cyst, but significantly correlated to dural adhesion of the cyst.Since neither clinical recovery nor recurrence rates do depend on complete removal of the cyst, aggressive resection of dural adherend parts of the cyst wall should be avoided to prevent CSF leakage.

Fibrin glues — the current state of knowledge

Fibrin glue is a two-component biological material obtained as result of extemporaneous preparation of equal volumes of fibrinogen concentrate and thrombin solution. On a mass scale fibrin glue is acquired either commercially by way of plas ma fractionation, or in laboratory setting by chemical precipitation or cryoprecipitate method. Fibrin glue mimics the blood clotting mechanism. Thrombin converts fibrinogen into fibrin clot, which — due to hemostatic properties contributes to sealing the wound and supporting damaged tissue regeneration. The clot adheres to adjacent tissues, and the structure becomes a natural scaffold for precursor and effector cells as well as hematopoietic growth factors that actively promote wound healing. Fibrin glue has found application as wound sealant mostly for patients with coagulation factor deficiencies and problems with spontaneous wound repair. The material is commonly used i.a. in general surgery (wound sealing or vascular suture ), regenerative surgery (bone implant fixation), plastic surgery (better cosmetic results, prevention of unaesthetic scarring), skin tissue regeneration for burn injury, neurosurgery (prevention of cerebrospinal fluid leak and nerve repair), cardiovascular surgery and stomatology. Fibrin glue embedded with drugs, antibiotics, cytostatic agents or stem cells, may increase the effectiveness of therapy and facilitate targeted delivery of active substances for localized drug release. The aim of the article is to present the current state of knowledge on the methods of preparation and application of fibrin sealants as well as on other possible use in various fields of medicine.

Clinical Feasibility of Completely Autologous Fibrin Glue in Spine Surgery.

Introduction Fibrin glue is widely used in spine surgery. Nevertheless, no report has demonstrated the feasibility of completely autologous fibrin glue (CAFG) in spine surgery. This study aims to investigate the safety, efficacy, and effect of bone fusion of CAFG on spine surgery. Methods We retrospectively extracted data of patients who underwent primary spine surgery with preoperatively prepared CAFG. Primary outcomes were the incidence of wound-related unplanned reoperations within 90 days following primary surgery and the occurrence of reoperation for the management of cerebrospinal fluid (CSF) leakage in patients who had been treated with CAFG used as dural sealants. The effect of CAFG on bone fusion was also assessed by detecting implant failure at one year postoperatively in patients aged 25 years or less undergoing primary fusion for idiopathic scoliosis. Results We identified 131 eligible patients (47 males and 84 females) with a mean age of 32.3 years. CAFG was used most frequently as an adhesive for fixation of graft bone (110 patients), followed by as a dural sealant for CSF leakage in 17 patients, and as a local hemostatic agent in four patients. Wound-related reoperations were identified in four patients (3.1%), which included three for surgical site infection, and one for postoperative epidural hematoma. There was no reoperation required for the management of CSF leakage among 17 patients with dural incision or incidental durotomy. Compared with the control cohort, the use of CAFG was not associated with early wound-related reoperations or implant failure in patients with spinal deformity. Conclusions We demonstrated the clinical feasibility of CAFG in spine surgery. The use of CAFG was not associated with the incidence of reoperations for wound-related complications. CAFG worked effectively as a dural sealant for preventing CSF leakage. CAFG had no beneficial or adverse effect on spinal bone fusion.

A Multilayered Dural Repair Technique Using Duragen for Early Cranioplasty Following Decompressive Craniotomy

Decompressive craniotomy is a neurosurgical emergency procedure in which a large skull bone is removed and the dura matter is extensively opened. Duraplasty is required to avoid cerebrospinal fluid (CSF) leakage during the decompressive craniotomy. DuraGen® is a safe and effective type I collagen matrix graft, which is frequently used in decompressive craniotomy procedures. Since DuraGen® does not require labor-intensive suturing, the operative time is shortened by DuraGen® closure with sufficient tightness preventing CSF leakage. Recently, early cranioplasty is preferred to achieve efficient rehabilitation after decompressive craniotomy. Although evidence of efficacy and safety of DuraGen® has been increasing in the management of duraplasty, no reports have previously discussed the condition of DuraGen® during the second surgery (cranioplasty) at this early timing. DuraGen®-derived neodura develops a mature dura 1 year post its placement, and the neodura remain fragile at this early time point. A deconstructed fragile neodura may result in postoperative CSF leakage. Here, we illustrated a multilayered dural repair technique with DuraGen® to avoid disruption of the fragile neodura during early cranioplasty.

Evaluation of the safety and effectiveness of a sealant hemostatic patch for preventing cerebrospinal fluid leaks in cranial surgery

ABSTRACT Background Cerebrospinal fluid (CSF) leak remains a significant source of morbidity after neurosurgical procedures. The objective is to evaluate the effectiveness and safety of a polyethylene glycol-coated collagen patch (PCC) in different neurosurgical procedures. Methods A retrospective, single-center cohort study in patients who underwent a cranial neurosurgical procedure. After collecting multiple data variables, patients were divided into two groups depending on the use of PCC as sealant on dural closure following procedures. Results Data from 230 patients were collected (PCC, 128; control group, 102). Incidence of CSF leakage was significantly lower in the PCC group (p < .001). Complications that were significantly lower in PCC than the control group included surgical infection (p = .022), and hydrocephalus (p = .017), as well as reduced rates of reintervention (p < .001) and shorter hospital stays (p = .028). Factors associated with a higher incidence of CSF leakage included posterior fossa procedures, reinterventions, and the need for CSF drainage placement. PCC reduced the risk of suffering CSF leakage by more than 75% (p = .002) once adjusted for age, surgical approach, type of cranial opening, reintervention, CSF drainage, dural substitute, and dural defect coverage. Conclusions Our findings confirm PCC as an effective means of preventing CSF leakage following cranial neurosurgery with fewer associated complications.

Fish Gelatin-Based Absorbable Dural Sealant with Anti-inflammatory Properties.

Cerebrospinal fluid (CSF) leakage from the dura mater during craniotomy is a common complication, which is associated with infection, meningitis, pneumocephalus, and delayed wound healing. In the present study, we developed an absorbable fish gelatin-based anti-inflammatory sealant for dura mater sealing to prevent CSF leakage. Gelatin derived from Alaska pollock (ApGltn) was modified with α-linolenic acid (ALA), an omega-3 fatty acid that exhibits anti-inflammatory properties, and cross-linked with a poly(ethylene glycol)-based cross-linker to develop ALA-ApGltn sealant (ALA-Seal). ALA-Seal demonstrated a higher storage modulus and tangent delta (tan δ) compared with those of the original ApGltn sealant (Org-Seal). The swelling ratio of ALA-Seal was markedly lower than that of DuraSeal, a commercially available dural sealant. Ex vivo burst strength measurements using porcine dura mater indicated that there was no significant difference between DuraSeal and ALA-Seal, despite ALA-Seal having an order of magnitude lower storage modulus. The anti-inflammatory properties of ALA-Seal, evaluated using brain microglial cells, were considerably higher than those of DuraSeal and Org-Seal, with a minimal adverse effect on cell viability. Therefore, compared to DuraSeal, ALA-Seal is a potential dural sealant with a lower swelling ratio, similar burst strength, and higher anti-inflammatory properties, which may prevent CSF leakage.