Prevention Of Cerebrospinal Fluid Leakage Research Articles

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.

Osaka Sliding Knot Seals Dural Defect Simply in Extended Endoscopic Endonasal Approach

An extended endoscopic endonasal approach (EEA) has become standard for parasellar and midline skull base lesions. However, postoperative leakage of cerebrospinal fluid (CSF) can result from dural defects after lesion removal. We present a simple and effective technique, the Osaka sliding knot, to prevent CSF leakage. Between November 2018 and March 2021, a total of 41 patients underwent reconstruction of skull base defects with intraoperative high-flow CSF leaks after extended EEA by using this closure technique, of whom only 1 patient experienced postoperative CSF leakage. This technically simple and efficient method seals the dural defect to prevent CSF leakage after surgeries using an extended EEA.

Prevention of cerebrospinal fluid leak after vestibular schwannoma surgery: a case-series focus on mastoid air cells' partition.

Petrous bone pneumatization may be related to cerebrospinal fluid (CSF) leak secondary to vestibular schwannoma surgery. To assess the association between petrous bone pneumatization and CSF leak in vestibular schwannoma surgery. A retrospective study included 222 consecutive vestibular schwannoma patients treated via a retrosigmoid or translabyrinthine approach in a 17-year period in one University Hospital. Association of CSF leak and petrous bone pneumatization, as seen on CT scans, was assessed on ANOVA and Student's t or Chi-squared test in case of non-parametric distribution. One hundred and 75 resections were performed on a retrosigmoid approach and 47 on a translabyrinthine approach. Mean age was 53.6 ± 12.9years. Mean follow-up was 5years 6months. Twenty-six patients (11.7%) showed CSF leak and 8 (3.6%) meningitis. Approach (p = 0.800), gender (p = 0.904), age (p = 0.234), body-mass index (p = 0.462), tumor stage (p = 0.681) and history of schwannoma surgery (p = 0.192) did not increase the risk of CSF leak. This risk was unrelated to mastoid pneumatization (p = 0.266). There was a highly significant correlation between internal acousticus meatus (IAM) posterior wall pneumatization and CSF leak after retrosigmoid surgery (p = 0.008). Eustachian tube packing in the translabyrinthine approach did not decrease risk of CSF leak (p = 0.571). Degree of petrous bone pneumatization was not significantly related to risk of CSF leak, but pneumatization of the posterior IAM wall increased this risk in retrosigmoid surgery. Eustachian tube packing in the translabyrinthine approach is not sufficient to prevent postoperative CSF leak. Both approaches had similar rates of CSF leaks, around 12%.

Preventing cerebral spinal fluid leakage following endoscopy through a burr hole using a novel watertight closure: technical note

Background Cerebrospinal fluid (CSF) leakage is a common complication after neuroendoscopic surgery through a burr hole and can lead to further complications including infection. Methods We describe the use of a dural substitute larger than the burr hole itself, placed over the burr hole and then secured underneath a burr hole cover by microscrews running through the graft itself into the underlying skull. Results This simple technical modification contributes to achieving a watertight seal to aid in preventing CSF leakage in this setting. Conclusions Our technical modification of endoscopy through a burr hole may help to prevent postoperative CSF leak and secondary CSF infections.

Preventing Post Dural Puncture Headache after Intrathecal Drug Delivery System Implantation Through Preventive Fibrin Glue Application: A Retrospective Study

Cerebrospinal fluid (CSF) leakage resulting in post dural puncture headache (PDPH) is a frequent adverse effect observed after intrathecal drug delivery system (IDDS) implantation. CSF leakage symptoms negatively affect patient quality of life and can result in additional complications. Fibrin glue was used to treat CSF leakage syndrome. We developed a procedure to reduce the incidence of PDPH by preventing CSF leakage with the use of fibrin glue during surgery. The main outcome criterion for this study was the incidence of PDPH syndrome after IDDS implantation with or without preventive fibrin glue application during the procedure. We designed a monocentric retrospective cohort study to compare the incidence of PDPH due to CSF leakage syndrome after lumbar puncture in patients with an implanted intrathecal pump, with or without preventive fibrin glue application during the procedure. The study was held in the Anesthesiology and Pain department of the Integrative Cancer Institute (ICO), Angers - France. The study compared 2 patient cohorts over 2 successive periods. Fibrin glue was injected into the introducer needle puncture pathway after placement of the catheter immediately following needle removal. The no-glue group included 107 patients, whereas the glue group included 92 patients.Two application failures were observed (2.04%). Fibrin glue application results in a significant decrease in PDPH incidence, from 32.7% in the no-glue group to 10.92 % (P < 0.001) in the glue group. In regard to severity, in the no-glue group, 37.1% of PDPH syndromes were mild, 34.3% were moderate, and 28.6% were severe. In the fibrin glue group, 80% of PDPH syndromes were mild, and 20% were moderate. No severe PDPHs were reported after fibrin glue application. Duration of symptoms was also statistically shorter in the fibrin glue group (maximum of 3 days vs. 15 days in the no-glue group). In a univariate analysis, preventive fibrin glue application and age are significant to prevent PDPH. In multivariate analysis, only fibrin glue application was statistically significant (odds ratio, 0.26; P = 0.0008). No adverse effects linked to fibrin glue were observed. The main limitation of this study is its retrospective nature. In addition, this study is from a single center with a potential selection bias and a center effect. The novel use of fibrin glue is promising in terms of its effect on PDPH and its safety profile. Its moderate cost and reproducibility make it an affordable and efficient technique.

Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy.

Objective To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting Set at the tertiary skull base center. Methods This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.

Use of tissue sealant patch (TachoSil) in the management of cerebrospinal fluid leaks after anterior cervical spine discectomy and fusion

Purpose The purpose of this study was to evaluate a fast, sutureless technique to repair anterior cervical dural tears. Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of cervical degenerative diseases. Although uncommon, incidental durotomy with cerebrospinal fluid (CSF) leak during ACDF is a potentially serious complication. Yet, its technical management for the prevention of CSF leak is controversial. Methods Between September 2012 and June 2018 we encountered seven cases (2 female/5 male) presenting with intraoperative CSF leaks secondary to incidental dural tears during ACDF surgery. All the cases were surgically treated using a topical fibrin sealant patch (TachoSil) with high adesive strength and fibrin glue (Tisseel). Intraoperative source of leakage, time to leakage control, quantity of Sealant Sponge used and postoperative complications were evaluated. Results Dural tears were tipically the result of dissection of adherent posterior longitudinal ligament and/or calcified disc from the cervical dural sac to allow full decompression of the spinal cord. Effective repair of dural tear defined as cessation of CSF leak after topical sealant agents application was achieved no later than one minute in all cases. Evident clinical and/or radiological postoperative CSF leak was used to determine the patient’s postoperative result. Postoperative CSF leak was not evident during a minimum 6 months follow up. Conclusions In the present study, we have reported our experience with a new sealing technique to manage CSF leaks from iatrogenic cervical dural lacerations. Tachosil tissue sealant patch is a rapid sutureless technique that may help in repairing introperatively incidental dural tears, thus reducing the risk of postoperative CSF leaks. To our knowledge, this is the first series to report the use of Tachosil adhesive sealant patch for the treatment of incidental dural tears during anterior cervical discectomy.

Reconstruction of Anterior Skull Base Fracture Using Autologous Fractured Fragments: A Simple Stitching-Up Technique.

ObjectiveA displaced fracture in the anterior cranial base may be complicated by cerebrospinal fluid (CSF) rhinorrhea and enophthalmos. This study introduces a reconstruction technique with direct dural repair and reduction and fixation of the autologous fractured fragments.MethodsDisplaced fractures in the anterior cranial base were reconstructed using a stitching-up technique: A bicoronal scalp incision and frontal craniotomy was performed and the displaced bone was withdrawn. The lacerated dura was repaired primarily using a graft. Small holes were created in the intact cranial bones and the displaced harvest bone. Black silk was passed through the holes and the displaced bone was repositioned on tying the silk. Lumbar drain was not placed in any of the cases. The feasibility and outcome were evaluated.ResultsFive patients with displaced skull fractures of the anterior cranial base were included. All cases were men who had a direct impact on the forehead and/or eye. All the displaced fractures occurred in the orbital roof, and ethmoid bone fractures were present in 4 cases. Dural laceration was involved in 4 cases and repaired by placing artificial dura in 3 cases and a pericranial graft in 1 case. Following surgery, all cases were uneventful, and the anterior cranial fossa was well reconstructed. CSF leakage or enophthalmos did not occur in any of the cases.ConclusionDirect dural repair and autologous stitching-up reconstruction using the fractured fragment could be an effective method to prevent CSF leakage and enophthalmos in displaced fractures of the anterior cranial base.

Individualized Sellar Floor Reconstruction Method and Nursing Strategy for the Intraoperative Cerebrospinal Fluid Leakage Caused by Neuroendoscopic Transsphenoidal Pituitary Adenoma Resection

Objective: To explore the clinical effect of and the method and nursing strategy for sellar reconstruction for intraoperative cerebrospinal fluid (CSF) leakage in pituitary adenoma resection under neuroendoscopy. Methods: The data from 20 cases of intraoperative CSF leak caused by transsphenoidal pituitary adenoma resection were retrospectively analyzed. Six patients were treated with mucosal flap and artificial dural reconstruction of sellar (simple sellar floor reconstruction). In 45 patients, autologous fat, fascia lata, and artificial dura were used to repair and reconstruct the sellar floor (multilayer sellar floor reconstruction). After the operation, all patients underwent follow-up for 6 - 24 months. Results: Fifty patients were followed up without CSF leakage. One patient was cured after leakage of CSF through the lumbar cistern 1 month after discharge. Conclusion: For patients with CSF leakage during neuroendoscopic transsphenoidal pituitary adenoma resection, individualized sellar floor reconstruction should be adopted according to the degree of CSF leakage and the size of the sellar floor defect. Strict nursing measures can effectively prevent CSF leakage and reduce postoperative complications.

Novel Surgical Treatment of Recurrent CSF Leak by Temporoparietal Temporalis Myofascial Flap: A Series of 6 Cases

With the advent of modern endoscopes and a better anatomic understanding of the skull base, the indications of endonasal approaches are increasing. These procedures may be complicated by high rates of postoperative cerebrospinal fluid (CSF) leak, and reconstruction of the defect remains challenging. In the anterior skull base, vascularized grafts have been reported as superior in preventing CSF leakage and infection. The Hadad-Bassagasteguy flap, being a pedicled flap, is our first line flap to reconstruct the skull base. When we were not successful with this flap, we resorted to different flaps. We modified the originally described temporoparietal fascial flap by Fortes etal and applied clinically. The objective of this paper is to briefly describe the modification of the flap and to review the clinical outcome. From 2014 to 2018, in 6 cases of CSF leak with the appropriate indication, we used the temporoparietal myofascial flap repair that is a modification of the temporoparietal fascial flap by Fortes etal. We took all the 6 patients in our study and followed them up. All of the 6 repairs were successful, and no CSF leak was found just after the operation in 6- to 48-month follow-up. We recommend our modified novel temporoparietal myofascial flap as a very good option in case of failed cases of postoperative CSF leak.

Predictors of catheter-associated meningitis in pediatric patients after brain tumor surgery: A 10-year single center experience

ObjectiveTo evaluate the incidence of catheter-associated meningitis (CAM) in a pediatric population receiving brain tumor surgery, and to identify the major risk factors involved. MethodsWe retrospectively analyzed the medical and radiological records of 205 pediatric patients who received 251 external ventricular drains (EVDs) between January 2008 and December 2017. All patients less than 18 years old who underwent cerebrospinal fluid (CSF) diversion in the course of brain tumor surgery were included. Patients with central nervous system infection (CNS) at the time of EVD insertion were excluded. ResultsA total of 99 patients receiving 107 EVDs met the study selection criteria. Among this population, the incidence of CAM was 19.2%. Median time-to-infection was 5 days. CAM prolonged the period of drainage in 57.9% of the cases. An extended ICU stay (>3 days) was statistically significantly associated with the occurrence of CAM. In the multivariate analysis, the presence of a high-grade CNS tumor was a predictor of an extended intensive care unit (ICU) stay. Furthermore, CSF leakage along the catheter tunnel was an independent predictor of CAM. ConclusionOur data confirms CAM as a significant complication in the acute treatment of hydrocephalus associated with pediatric brain tumors. To limit the incidence of CAM, measures must be taken to prevent CSF leakage, particularly among patients with high-grade CNS tumors that are likely to stay longer in the ICU and need prompt postoperative radiotherapy and oncological treatment.

Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: a systematic review and meta-analysis

BackgroundPerioperative cerebrospinal fluid (CSF) leakage is a major complication of pituitary adenomas transsphenoidal surgery. Lumbar drainage (LD) is a common method of treating CSF leakage. But whether intraoperative LD can prevent CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery remains controversial. Clarity on the appropriate use of LD is needed.MethodsA systematic literature review was conducted in the PubMed, EMBASE, and Web of science databases. Articles were included when they compared intraoperative LD with intraoperative no-LD CSF leakage rates during pituitary adenomas transsphenoidal surgery.ResultsOverall, 5 studies containing 678 cases met the inclusion criteria. When data were provided on intraoperative CSF leakage rates, the meta-analysis showed a significant difference in favor of intraoperative LD. When data were provided on postoperative CSF leakage rates, the meta-analysis also demonstrated a significant difference in favor of intraoperative LD.ConclusionsAlthough the results of this meta-analysis suggest intraoperative LD can reduce the risk of CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery, the available evidence is indefinite. To some extent the results suggest intraoperative LD’s potential positive role. Further studies that include well-designed prospective, randomized controlled clinical trials are necessary for further verification.

Comparison of dorsal intercostal perforator artery flap and primary closure in myelomeningocele repair

Of the many suggested techniques, we used dorsal intercostal perforator artery flap (DIPAF) for the closure of myelomeningocele defects. This study compared the outcomes of primary closure and DIPAF in the closure of myelomeningoceles. Data of 24 patients that underwent myelomeningocele surgery at a single institution between November 2015 and September 2019 were retrospectively reviewed. The primary closure group had 13 patients (54.17%) and the DIPAF group had 11 (45.83%). The mean age was 7.91 ± 13.27days (1-60days). Twelve patients were female and 12 were male. In 22 patients, the myelomeningocele sacs were in the lumbosacral region, while in 2, they were in the thoracolumbar region. The mean defect sizes were 14.20 ± 4.62cm2 and 18.44 ± 3.49cm2 in the primary closure and DIPAF groups, respectively. In each group, four patients had a kyphotic deformity. In the primary closure group, three patients had wound necrosis, two had wound dehiscence, and four had cerebrospinal fluid (CSF) leakage. In the DIPAF group, one patient had wound necrosis and one had CSF leakage. Significantly fewer complications related to the operation area were observed in the DIPAF group (p < 0.05). Increased defect size, kyphotic deformity, and presence of hydrocephalus were found to be risk factors for complications related to the operation area. This surgical treatment protects neural tissue, prevent CSF leakage, and reduce central nervous system infection rates in myelomeningocele patients. Closure technique with the fasciocutaneous skin flap has more satisfying results than primary closure.

Is the Postoperative Horizontal Decubitus Position Following Transection of a Tight Filum Terminale in Pediatric Patients Necessary? - A Retrospective Cohort Study.

After untethering surgery of a tethered spinal cord of a tight filum terminale, patients are usually kept in the horizontal decubitus position to prevent cerebrospinal fluid (CSF) leakage. However, the optimal period for keeping these patients in this position has not been established yet. Surgical results in two groups of pediatric patients with a tight filum terminale were retrospectively analyzed. Group A was maintained in the horizontal decubitus position for 72 h and group B was managed without being kept in this position postoperatively. A total of 313 patients underwent sectioning of a tight filum terminale. Of these patients, 144 were maintained horizontally for 72 h postoperatively (group A) and 169 were managed without this position (group B). Among the patients who were maintained horizontally for 72 h, one (0.7%) developed pseudomeningocele. No patients experienced CSF leakage in this group. Among the patients who were not horizontal, one (0.6%) developed CSF leakage and one (0.6%) developed pseudomeningocele. Maintaining patients without restriction of their position does not appear to change the rate of postoperative CSF leakage or pseudomeningocele. This suggests that maintaining patients horizontally after transection of a tight filum terminale is not necessary for preventing CSF leakage.

Localized controlled fibrin glue application with gelatin sponge for hemostasis and dural defect repair: Technical note

ObjectivesHemostasis and dural defect repair are fundamental aspects of neurosurgical procedures. Some significant bleeding may be caused by dural tears (e.g. bleeding from cerebral dural venous sinuses). Various methods have been previously reported for these purposes, utilizing commercially available surgical materials such as gelatin sponge and fibrin glue. We describe a simple, yet versatile and flexible technique with a critical modification to the previously known combined use of gelatin sponge and fibrin glue. We then present a few illustrative cases and discuss the utility and advantages of the described technique. Patients and methodsThe described technique involves separate and sequential application of fibrinogen solution followed by thrombin solution of fibrin glue over gelatin sponge, which enables hemostasis or dural defect repair in a localized, controlled manner. ResultsWe have utilized this technique effectively for hemostasis and dural defect repair in a variety of neurosurgical procedures for over 10 years. We have found the technique to be highly useful and effective, although the effectiveness of this technique may be difficult to quantify objectively and independently of the other standard surgical maneuvers, given that hemostasis and prevention of cerebrospinal fluid leak is multifactorial. We have not encountered any complications specifically attributable to the use of fibrin glue and/or gelatin sponge for this technique. ConclusionThis technique will add to the neurosurgeons' arsenal for hemostasis and dural defect repair, in addition to the more standard and basic surgical maneuvers.

Sandwich technique using fibrin-coated collagen fleece for sellar reconstruction in large dural defects during transsphenoidal surgery

PurposeVarious surgical methods to prevent intraoperative and postoperative cerebrospinal fluid (CSF) leaks during transsphenoidal approach (TSA) surgeries have been reported, but surgical techniques to address large dural defects have been less thoroughly investigated in the literature. The authors retrospectively evaluated the usefulness of the sandwich technique using fibrin-coated collagen fleece (TachoSil) to prevent intraoperative CSF leakage from large dural defects in TSA surgery. MethodsIn total, 101 cases of intraoperative CSF leaks were observed among 465 patients who underwent TSA surgery at a single university hospital between 2002 and 2014. Among them, cases with Grade 3 intraoperative CSF leakages and large diaphragmatic/dural defects were reconstructed via the sandwich technique using TachoSil or via the conventional technique using simple intrasellar packing with fat or synthetic materials, and these cases were enrolled in this study. ResultsA total of 28 cases with Grade 3 intraoperative CSF leakages were identified and analyzed. The sandwich technique using TachoSil was applied in 13 cases, and the conventional technique was applied in 15 cases. The postoperative CSF leakage was significantly decreased by the sandwich technique as compared to the conventional technique (retrospectively, 0 cases vs. 4 cases (30.8%); P=0.044). ConclusionThe sandwich technique using TachoSil can effectively prevent CSF leakage in cases with large dural defects during TSA surgery.

Safety and Efficacy of TachoSil (Absorbable Fibrin Sealant Patch) Compared With Current Practice for the Prevention of Cerebrospinal Fluid Leaks in Patients Undergoing Skull Base Surgery: A Randomized Controlled Trial.

Cerebrospinal fluid (CSF) leakage associated with incomplete sealing of the dura mater is a major complication of intradural procedures. To compare the efficacy and safety of adjunctive TachoSil (Takeda Pharma A/S, Roskilde, Denmark) with current practice for the prevention of postoperative CSF leaks in patients undergoing elective skull base surgery involving dura mater closure. Patients were intraoperatively randomized to TachoSil or current practice immediately before primary dura closure by suturing ± duraplasty. Choice of adjunctive treatment in the current practice group was at the surgeon's discretion. Primary efficacy endpoint was occurrence of clinically evident verified postoperative CSF leak or clinically evident pseudomeningocele within 7 weeks after surgery or treatment failure (third application of trial treatment or use of other treatment). A total of 726 patients were randomized to TachoSil (n = 361) or current practice (n = 365). More current practice patients had sutures plus duraplasty for primary dura closure compared with TachoSil (49.6% vs 35.7%) and fewer had sutures only (45.5% vs 63.2%). The primary endpoint of estimated leak rate favored TachoSil with events in 25 (6.9%) patients vs 30 (8.2%) current practice patients; however, this was not statistically significant (odds ratio: 0.82; 95% confidence interval: 0.47, 1.43; P = .485). Both treatments were well tolerated with similar frequency of adverse events. Very low rates of postoperative CSF leaks can be achieved in patients undergoing skull base surgery of various indications. Although the study did not meet its primary endpoint, TachoSil appears to be safe and effective for the prevention of CSF leaks and associated complications.

Clinical Application of Scalp Markers and Three-Dimensional Sliced Computed Tomography Reconstructions of the Skull Transverse-Sigmoid Sinus Groove in the Retrosigmoid Approach.

To explore the clinical value of bone flap creation and the sinus protection in the approach of retrosigmoid keyhole craniotomy with the guidance of three-dimensional (3D) sliced computed tomography (CT) reconstruction of the skull transverse sinus and sigmoid sinus groove. The scalp tracings of the transverse sinus and sigmoid sinus groove of 108 posterior fossa lesion patients were delineated by gentian violet, which relies on the relationship between its 3D reconstruction location and scalp marker. The craniotomy was executed with the guidance of its surface tracings. The intraoperative findings of exposure and damage of transverse sinus, sigmoid sinus, morphology, stability, complications, and postoperative appearance of bone flap restoration were evaluated. Morphological analysis of the transverse-sigmoid sinus groove showed right superiority, left superiority, and balanced type in 61, 18, and 29 cases, respectively and the relationship between the asterion and the transverse-sigmoid sinus groove showed that asterion sites were located in the upper portion, onto, and below the transverse and sigmoid sinus groove in 19, 68, and 21 cases, respectively. Good intraoperative exposure without damage of transverse sinus and sigmoid sinus, good stability and appearance of bone flap restoration, and no postoperative pseudomeningocele were obtained after using this method to locate the transverse sinus and sigmoid sinus. The 3D sliced CT reconstruction of the skull transverse sinus and sigmoid sinus groove was helpful in the approach of retrosigmoid craniotomy for sinus exposure, sinus protection, and the prevention of cerebrospinal fluid leakage and pseudomeningocele.