Reconstruction Of Dura Mater Research Articles

Grading System and Surgical Strategy for Temporal Bone Diffuse-Type Tenosynovial Giant Cell Tumor.

To develop a novel grading system and appropriate surgical approaches for patients with diffuse type tensosynovial giant cell tumor (D-TGCT) of the temporal bone. Retrospective cohort study. We retrospectively reviewed 31 patients with temporal bone D-TGCT between June 2012 and July 2021. All patients underwent comprehensive clinical evaluations, including clinical presentations, hearing threshold, imaging studies, surgical approaches, and prognosis. A grading system was developed based on the tumor location and adjacent neurovascular structures involvement according to imaging and intraoperative findings. In this study, grade II tumors were the most common (13/31), followed by grades I (7/31), III (7/31), and IV (4/31) tumors. Seven grade I patients received the subtemporal middle cranial fossa approach (SMCF) combined with the canal wall up mastoidectomy and tympanoplasty (CWUT). Nine grade II patients underwent SMCF combined with subtotal petrosectomy (SPTR), and four grade II patients underwent SMCF combined with CWUT. Seven grade III patients received SMCF combined with SPTR and dura mater reconstruction, and four grade IV patients underwent infratemporal fossa approach type B. Gross total resection was achieved in all patients, and the median follow-up time was 30.1 months (range, 4-96 months). Three patients (one grade II, one grade III, and one grade IV) had recurrence during follow-up, and the patient with grade III tumor had two recurrences. Gross total resection is the first-line treatment for patients with D-TGCT of the temporal bone. This novel grading system enables surgeons to select optimal surgical strategy. Long-term follow-up is mandatory postoperatively. 4 Laryngoscope, 132:1275-1284, 2022.

Applications of materials for dural reconstruction in pre-clinical and clinical studies: Advantages and drawbacks, efficacy, and selections.

The dura mater provides a barrier to protect the tissue underneath and cerebrospinal fluid. However, dural defects normally cause cerebrospinal fluid leakage and other complications, such as wound infections, meningitis, etc. Therefore, the reconstruction of dura mater has important clinical significance. Current dural reconstruction materials include: homologous, acellular, natural, synthetic, and composite materials. This review comprehensively summarizes the characteristics and efficacy of these dural substitutes, especially in clinical applications, including the advantages and drawbacks of those from different sources, the host tissue response in pre-clinical studies and clinical practice, and the comparison of these materials across different surgical procedures. Furthermore, the selections of materials for different surgical procedures are highlighted. Finally, the challenges and future perspectives in the development of ideal dural repair materials are discussed.

The Helmet-Visor Pericranial Flap as a Viable Option for Anterior Cranial Base Reconstruction in Complex Oncologic Cases

To describe a novel bilaterally pedicled pericranial flap for anterior cranial base reconstruction after removal of complex frontobasal cancers extending to the frontal region, thus precluding the use of standard reconstructive techniques. In selected oncologic cranial base surgeries, the use of the standard galea frontalis pericranial flap for reconstructive purposes may be precluded by tumor infiltration. In such cases, dura mater reconstruction and exclusion of frontal sinuses from the intracranial space can be performed using a large superficial temporal artery bilaterally pedicled pericranial flap obtained from both temporoparietal regions. Surgical technique, indication, contraindication, complications, and degree of resection are recorded to evaluate the efficacy of this surgical method. A 48-year-old man affected by a recurrence of frontobasal squamous cell carcinoma was surgically treated by combined transcranial and endoscopic endonasal resection. A large pericranial flap pedicled bilaterally on the parietal branches of the superficial temporal artery was obtained, transposed anteriorly, carefully watertight sutured to the dural defect, and used to exclude cranialized frontal sinuses as well. The reconstruction was successful, and the patient was discharged home on the tenth postoperative day without any complications and/or development of cerebrospinal fluid leak. Contrast-enhanced magnetic resonance imaging 3 months after surgery was clear from disease with consolidated surgical outcomes. This novel pericranial flap seems to be easily obtained and effective for anterior cranial base reconstruction when the use of a traditional galea frontalis flap is precluded for oncologic reasons and there are concerns for the possible development of contaminations and cerebrospinal fluid leaks.

Endoscopic endonasal diagnosis and treatment of skull base meningoencephalocele

The study purpose was to determine the successful outcome rate of endoscopic endonasal reconstruction of skull base CSF fistulas with removal of meningocele as well as analyze disease relapses. The second purpose of the study was to describe the treatment outcomes, depending on the type, location, and size of meningocele as well as on a technique used to reconstruct the skull base defect. Three hundred and eleven patients diagnosed with cerebrospinal fluid (CSF) rhinorrhea who underwent surgery at the Burdenko Neurosurgical Institute in the period between 2007 and 2014 were retrospectively analyzed. Meningocele was detected in 141 (45.3%) of all patients with CSF rhinorrhea. The diagnosis was made before surgery and verified during endoscopic endonasal reconstructive closure of skull base defects. Therefore, the analysis group included all cases of meningocele and meningoencephalocele verified during surgery. The study analyzed the gender, age of surgery, follow-up period, comorbidities, use of lumbar drainage, etiology of the defect, localization, type of reconstructive material, complications, and disease relapses. We defined the efficacy of endoscopic endonasal meningocele resection with fistula reconstruction as the absence of signs of CSF rhinorrhea and a hernia sac based on the data of control CT and endoscopy performed in the late postoperative period. The follow-up period ranged from 1 month to 5 years. All patients underwent endoscopic endonasal reconstruction of the skull base defect. The treatment efficacy was 110 (78%) patients for primary surgery and 26 (84%) patients for repeated surgery. Endoscopic endonasal surgery is a safe, effective, and minimally invasive technique for treatment of meningocele and meningoencephalocele, which enables resection of a hernia sac and reconstruction of dura mater and skull base defects.

A technique of TachoComb application in dura mater reconstruction in surgery for posterior cranial fossa tumors

Liquorrhea is a condition characterized by cerebrospinal fluid (CSF) leakage from the cranial cavity due to injury to the integrity of the dura mater (DM) and bone structures of the skull base. Surgery for posterior cranial fossa (PCF) lesions distinguishes wound CSF leakage when CSF leaks from a surgical wound as well as basal CSF leakage (nasal liquorrhea and, less often, otoliquorrhea). The main cause of basal CSF leakage is injury (including surgical injury) resulting in a defect in the DM and bone structures (cells of the mastoid process in the case of a suboccipital retrosigmoid approach). There are a variety of DM restoration techniques ranging from DM closure or placement of a synthetic or autologous patch to application of various synthetic adhesives in the form of adhesive compositions (Tissucol) and adhesive substances (TachoComb). This article describes the experience with application of a TachoComb® sponge gained at the 5th Clinical Department of the Burdenko Neurosurgical Institute. The study included 176 patients with acoustic neurinomas. At the final stage of surgery, all the patients underwent DM reconstruction with a TachoComb® collagen sponge. CSF leakage occurred in 3 (1.7%) patients, with each of them having Koos grade 4 tumor. One (0.56%) patient had wound liquorrhea, and 2 (1.1%) patients had nasal liquorrhea. CSF leakage was managed by placement of a lumbar drain; postoperative wound revision was not required. Using the TachoComb® sponge for DM reconstruction in PCF surgery is an effective way to prevent postoperative CSF leakage, provided that the algorithm of manipulations described in the article is followed.

Split cord malformation type I: Technical notes on the subject of a rare variant of a rare malformation

Background: Split cord malformation type I is a rare form of occult spinal dysraphism. A median septum arising from vertebral arches is an exceedingly rare variant with only a few cases described. Methods: Description of clinical case and surgical technique. Results: We describe the case of a neurologically intact 2-year-old boy who was diagnosed with a split cord malformation type I. Radiological examination revealed an osseous septum in the vertebral canal arising from L2 and L3 arches and separating two independent hemicords. Septum removal, cord partial untethering and duramater reconstruction were performed without associated morbidity. The patient has been followed by a multidisciplinary team for five years. A subtle and non progressive left foot deformity was observed. We review practical aspects of the surgical treatment of this malformation. Conclusion: The diagnosis of associated vertebral malformations and tethering lesions is critical. Paramedian laminectomy, subperiosteal spur dissection and watertight reconstruction of posterior duramater represent important technical variations related to the posterior origin of the median septum.

Treatment for infection of artificial dura mater using free fascia lata.

Synthetic artificial dura mater materials, such as expanded polytetrafluoroethylene sheets, are widely used in dura mater reconstruction in cases involving brain tumors or trauma surgery. In patients with postoperative infection related to the use of artificial dura mater, surgical debridement of the infected wound and removal of the artificial dura mater materials are necessary to control infection. In cases involving cerebrospinal fluid leakage, dura mater reconstruction must be performed immediately. Many useful techniques for performing dura mater reconstruction to treat postoperative infection have been reported; however, some have drawbacks with respect to the need for microvascular anastomosis or difficulties in obtaining watertight closure. We successfully treated 6 patients with postoperative artificial dura mater infection using free thigh fascia lata. Some surgeons believe that the use of free fascia in infected wounds is dangerous because free fascia is a non-vascularized tissue. However, performing complete debridement and covering such free fascia with well-vascularized tissue allow the fascia to become vascularized and tolerant of infection. Therefore, if the blood flow in the scalp is acceptable after a sufficient debridement, free fascia lata can be used for reconstruction in patients with postoperative infection of artificial dura mater. Furthermore, skull reconstruction can be performed safely and easily with solid-type artificial bone, sometimes combined with tissue expansion, thus resulting in good aesthetic outcomes.

Staged Reconstruction of Infected Dura Mater Using Vascularized Rectus Abdominis Muscle

Alloplastic synthetic dura is widely used in dura mater reconstruction. Although the incidence of postoperative alloplastic dura infection is not common, the possibility of intractable postoperative wound infection despite appropriate antibiotic use exists. Rectus free flap is composed of well-vascularized muscle and fascial tissues. This flap is appropriate for volumetric replacement in large defects, whereas the fascia is appropriate for dura mater reconstruction. We report a case of successful reconstruction in a patient who had intractable postsurgical wound infection with staged operation using vascularized rectus muscle and fascial flap in a patient with meningioma reconstructed with alloplastic dura graft (Neuropatch; B. Braun Melsungen AG, Melsungen, Germany) and additionally achieved aesthetic results. In the first step, vascularized rectus fascia and muscle were transferred to contaminated reconstructed dura after craniectomy. The removed calvarial bone was banked to the abdominal donor-site pocket after cleansing. Finally, in the second stage, cranioplasty was performed with the banked autologous calvarial bone.

CO₂ Laser Soldering for the Reconstruction of Dural Defects in the Minipig Model.

To explore the feasibility and reliability of CO₂ laser soldering on the reconstruction of dura mater in the minipig model. Ten minipigs were divided into 2 groups as Group A (n=5) and Group B (n=5). Bilateral fronto-parietal craniotomy was performed and 2 cm × 1 cm dural defect created under general anesthesia. Then, the defect was repaired with autologous temporalis fascia by CO₂ laser soldering. After pressure and watertightness testing, the minipigs of group A were sacrificed immediately. Minipigs in Group B were followed for 4 weeks, with daily monitoring of behavior, food intake, skin incision and neurological condition. Animals of Group B were also subjected to the same tests as group A. Then, they were also sacrificed. The reconstructed area and underlying brain tissue were fixed in paraformaldehyde and submitted for histological analysis. No neural impairment, hydrops or empyema, and no cerebrospinal fluid leak in the dura-fascia interface were observed in Group B. The mean burst pressures were higher than the mean intracranial crest pressure in groups A and B. This difference was significant (P=0.010, P=0.000, respectively). The physiological intracranial pressure of ten minipigs ranged between 4.53 and 6.47 mmHg. No thermal injury was observed in either group. CO₂ laser soldering for dural defect reconstruction was feasible and reliable.

Two-Stage Reconstructive Surgery of a Patient with Head Trauma Resulting in Extensive Cranial Bone and Dura Mater Loss Caused by Postoperative Infection

After external decompression for a case of head trauma, epidural abscess formation resulted in extensive cranial bone and dura mater loss, for which two-stage reconstructive surgery was conducted. In the first operation, after thorough debridement of the infected wound, the dura mater was reconstructed using a bipedicle pericranial flap with posterior and anterior pedicles. After the infection had completely subsided, the second operation was performed, reconstructing the cranium with grafted outer-table calvarial bone and cutting bone to reposition an old zygomatic fracture. At this point, the pericranial flap used for dura mater reconstruction in the first operation became a satisfactory graft bed for the grafted bone. The postoperative course was satisfactory, and there was no cranial bone absorption after roughly 2 year, and a favorable shape has been maintained for an extremely satisfying result.

Posterior cranial fossa surgery in 454 children. Comparison of results obtained in pre-CT and CT era and after various types of management of dura mater.

At the Department of Neurosurgery, Hradec Kralové, 454 children (aged under 18 years) were operated on for posterior cranial fossa lesions in a period of 49 years (1948-1996). The majority (402) had tumours: cerebellar astrocytomas 149 (37.1%), medulloblastomas 139 (34.6%), brain stem gliomas 46 (11.4%), ependymomas 28 (7.0%), and others 40 (9.9%). Postoperative mortality was compared for the pre-CT era (1948-1977) and the CT era (1978-1996): astrocytomas (8.6%:4.7%), medulloblastomas (14.9%:2.9%), brain stem gliomas (21.7%:19.0%), ependymomas (18.2%:6.3%), and others (40.0%:7.4%). The initially high mortality was due to insufficient intracranial decompression, brain oedema and disturbances of cerebrospinal fluid circulation. Obstructive hydrocephalus was treated in 53 children with tumours and 25 with aqueduct stenoses, by Torkildsen's drainage in 5.5%, and/or by catheterisation of aqueduct in 12.3%. The main postoperative complications of medial posterior fossa surgery in 429 children operated on were: pseudomeningocele (12.3%), active hydrocephalus (6.2%) and CSF leakage (4.6%). Only 8.2% had shunts placed for these complications. We presume that this low percentage of shunts used results from a frequent use of duraplasties and drains installed at the primary operation. The dura mater was initially (1948-1954) left open (50 cases), and later (1955-1958) also sutured (37 cases), and from 1958, onward, and especially from 1961, reconstructed by a medial approach by means of various grafts (377 cases). In all, duraplasty was performed in 81.6% of cases. The grafts used for dura mater reconstruction were prepared from autogeneic (1.6%), allogeneic (72.3%), xenogeneic (24.8%), or synthetic (1.3%) material. They were successful in 99.2% of cases (all materials). Our own suture technique for posterior fossa duraplasty is presented.