Augmentation of dural closure following cerebro-spinal surgeries using Evicel- an experience of 105 patients in India

Background: For the neurosurgeon, CSF leaks are a frustrating post-operative complication, and for the patient, it can result in unanticipated morbidity and mortality. Immediate intra-operative recognition of incidental durotomy and dural closure may avoid it. Fibrin sealant is a two-component topical hemostat, dura sealant, and tissue adhesive consisting of fibrinogen and thrombin. We conducted this study to evaluate the efficacy of fibrin sealant Evicel in the management of postoperative CSF leaks as an adjunct to dural suture in patients undergoing a variety of neurosurgical procedures.Methods: This was a retrospective, single-center clinical study conducted on 105 patients who underwent elective neurological surgery from August 2015 to May 2016 at Sion Hospital, India. The efficacy endpoint was the prevention of clinically evident and verified postoperative CSF leak.Results: In all patients, the dural defect was effectively repaired intraoperatively, indicated by the absence of CSF leakage. The success rate of using Evicel was 100% in our cohort for the durasealant efficacy. No adverse effects were reported.Conclusions: We conclude that the use of fibrin sealant Evicel was successful to manage CSF leaks and achieve predictable watertight dural closure resulting in a reduction of intraoperative and postoperative fluid collections. It possesses an acceptable safety profile, consistent with previous findings from other similar studies and studies evaluating the role of Evicel in other surgical indications.

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The safety and effectiveness of a dural sealant system for use with nonautologous duraplasty materials

Journal of Neurosurgery ◽

10.3171/2009.6.jns081540 ◽

2010 ◽

Vol 112 (2) ◽

pp. 428-433 ◽

Cited By ~ 35

Author(s):

Jason S. Weinstein ◽

Kenneth C. Liu ◽

Johnny B. Delashaw ◽

Kim J. Burchiel ◽

Harry R. van Loveren ◽

...

Keyword(s):

Polyethylene Glycol ◽

Adverse Events ◽

Surgical Site Infections ◽

Study Group ◽

Pivotal Trial ◽

Safety And Efficacy ◽

Dural Closure ◽

System A ◽

Csf Leakage ◽

Csf Leaks

Object The DuraSeal dural sealant system, a polyethylene glycol hydrogel, has been shown to be safe and effective when used with commercial and autologous duraplasty materials. The authors report on the safety and effectiveness of this sealant when used in conjunction with nonautologous duraplasty materials. Methods In this retrospective, nonrandomized, multicenter study, the safety and efficacy of a dural sealant system was assessed in conjunction with primarily collagen-based nonautologous duraplasty materials in a sample of 66 patients undergoing elective cranial procedures at 3 institutions. This cohort was compared with 50 well-matched patients from the DuraSeal Pivotal Trial who were treated with this sealant system and autologous duraplasty material. Results The key end points of the study were the incidences of CSF leaks, surgical site infections, and meningitis 90 days after surgery. The incidence of postoperative CSF leakage was 7.6% in the study group (retrospective population) and 6.0% in the Pivotal Trial population. The incidence of meningitis was 0% and 4.0% in the retrospective and Pivotal Trial groups, respectively. There were no serious device-related adverse events or unanticipated adverse device effects noted for either population. Conclusions This study demonstrates that the DuraSeal sealant system is safe and effective when used for watertight dural closure in conjunction with nonautologous duraplasty materials.

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Spinal endoscopy combined with selective CT myelography for dural closure of the spinal dural defect with superficial siderosis: technical note

Journal of Neurosurgery Spine ◽

10.3171/2017.5.spine17233 ◽

2018 ◽

Vol 28 (1) ◽

pp. 96-102 ◽

Cited By ~ 4

Author(s):

Hidetaka Arishima ◽

Yoshifumi Higashino ◽

Shinsuke Yamada ◽

Ayumi Akazawa ◽

Hiroshi Arai ◽

...

Keyword(s):

Endoscopic Examination ◽

Technical Note ◽

Drainage Tube ◽

Superficial Siderosis ◽

Dural Defect ◽

Ct Myelography ◽

Dural Closure ◽

Spinal Subarachnoid Space ◽

Csf Leakage ◽

Dural Defects

The authors describe a new procedure to detect the tiny dural hole in patients with superficial siderosis (SS) and CSF leakage using a coronary angioscope system for spinal endoscopy and selective CT myelography using a spinal drainage tube. Under fluoroscopy, surgeons inserted the coronary angioscope into the spinal subarachnoid space, similar to the procedure of spinal drainage, and slowly advanced it to the cervical spine. The angioscope clearly showed the small dural hole and injured arachnoid membrane. One week later, the spinal drainage tube was inserted, and the tip of the drainage tube was located just below the level of the dural defect found by the spinal endoscopic examination. This selective CT myelography clarifies the location of the dural defect. During surgery, the small dural hole could be easily located, and it was securely sutured. It is sometimes difficult to detect the actual location of the small dural hole even with thin-slice MRI or dynamic CT myelography in patients with SS. The use of a coronary angioscope for the spinal endoscopy combined with selective CT myelography may provide an effective examination to assess dural closure of the spinal dural defect with SS in cases without obvious dural defects on conventional imaging.

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Sandwich wound closure reduces the risk of cerebrospinal fluid leaks in posterior fossa surgery

Clinics and Practice ◽

10.4081/cp.2016.824 ◽

2016 ◽

Vol 6 (2) ◽

Cited By ~ 3

Author(s):

Verena Heymanns ◽

Abidemi W. Oseni ◽

Ameer Alyeldien ◽

Homajoun Maslehaty ◽

Richard Parvin ◽

...

Keyword(s):

New York ◽

Cerebrospinal Fluid ◽

Posterior Fossa ◽

Wound Closure ◽

Posterior Fossa Surgery ◽

Dural Closure ◽

Csf Leakage ◽

Cerebrospinal Fluid Leaks ◽

Closure Method ◽

Csf Leaks

Posterior fossa surgery is demanding and hides a significant number of obstacles starting from the approach to the wound closure. The risk of cerebrospinal fluid (CSF) leakage in posterior fossa surgery given in the literature is around 8%. The present study aims to introduce a sandwich closure of the dura in posterior fossa surgery, which reduces significantly the number of CSF leaks (3.8%) in the patients treated in our department. Three hundred and ten patients treated in our hospital in the years 2009-2013 for posterior fossa pathologies were retrospectively evaluated. The dura closure method was as following: lyophilized dura put under the dura and sealed with fibrin glue and sutures, dura adapting stitches, TachoSil® (Takeda Pharma A/S, Roskilde, Denmark), Gelfoam® (Pfizer Inc., New York, NY, USA) and polymethylmethacrylate (osteoclastic craniotomy). The incidence of postsurgical complications associated with the dural closure like CSF leakage, infections, bleeding is evaluated. Only 3.8% of patients developed CSF leakage and only 0.5% needed a second surgery for CSF leakage closure. Two percent had a cerebellar bleeding with no need for re-operation and 3% had a wound infection treated with antibiotics. The sandwich wound closure we are applying for posterior fossa surgery in our patients correlates with a significant reduction of CSF leaks compared to the literature.

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A Comparative Study between Autologous Dural Closure versus Collagen Matrix (DuraGen) Closure in Decompressive Craniectomy for Trauma

Indian Journal of Neurotrauma ◽

10.1055/s-0039-1698713 ◽

2020 ◽

Vol 17 (01) ◽

pp. 46-49

Author(s):

Rajesh Kumar Barooah ◽

Basanta Kumar Baishya ◽

Hriday Haloi ◽

Mrinal Bhuyan ◽

Asman Ali ◽

...

Keyword(s):

Wound Infection ◽

Decompressive Craniectomy ◽

Operating Time ◽

Collagen Matrix ◽

Dural Defect ◽

Temporalis Fascia ◽

Dural Closure ◽

Fascia Graft ◽

Dural Graft ◽

Csf Leakage

Abstract Introduction Neurosurgeons often deal with the problem of a complete and watertight dural closure after cerebral operative procedures. In decompressive craniectomy done for trauma, autologous grafts such as galea, temporalis fascia can be time consuming. Hence this study was undertaken to look into the outcome using collagen matrix graft for dural closure. Aims and Objectives To study the difference between autologous dural graft closure and collagen matrix graft with respect to the time taken for closure, cerebrospinal fluid (CSF) leakage, and wound infection. Methods This prospective study includes 30 patients who underwent decompressive craniectomy for trauma. Duraplasty with temporalis fascia graft and nonautologous collagen matrix dural patch was done by randomization. Specific time points during craniectomy and cranioplasty was calculated. Total time for the procedures and the time for dural repair and separation was calculated. Results The use of collagen matrix in decompressive craniectomy resulted in decrease in mean operative time during the first surgery by average 45 minutes (p< 0.5) as compared to the use of autologous graft. There is reduction in the operating time during second surgery (cranioplasty) by 35 minutes (p< 0.5). The patients using collagen matrix graft did not record any CSF leakage or wound infection. Excellent uptake of the collagen by the duramater was seen. Conclusion The use of collagen to cover the dural defect for decompressive craniectomy for trauma results in significant reduction in the operating time during the first surgery and also in cranioplasty. There is reduction in CSF leakage and hence duration of hospital stay and cost.

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The Use of Lugol Test in Determining the CSF Leaks Location of the Anterior Skull Base

Revista de Chimie ◽

10.37358/rc.18.2.6115 ◽

2018 ◽

Vol 69 (2) ◽

pp. 400-402

Author(s):

Razvan Hainarosie ◽

Alexandru Meius ◽

Irina Ionita ◽

Mura Hainarosie ◽

Cristian Dragos Stefanescu ◽

...

Keyword(s):

Skull Base ◽

Intrathecal Injection ◽

Anterior Skull Base ◽

Diagnostic Methods ◽

Csf Leak ◽

Dural Defect ◽

Glucose Content ◽

Cerebrospinal Fluid Rhinorrhea ◽

Csf Leakage ◽

Csf Leaks

Cerebrospinal fluid rhinorrhea is a rare medical problem but with increased mortality potential due to the risk of meningitis. This condition can be either traumatic or nontraumatic, based on the etiology. The traumatic CSF fistulas represent almost 80% of the entire CSF fistulas, surgical procedures cause nearly 16% of the CSF leaks in the anterior skull base, and the nontraumatic CSF leaks represent only 4%, and they are divided in normal-pressure and high-pressure fistulas. The diagnosis of CSF leaks is made by demonstrating the evidence of extracranial CSF. The diagnostic methods are double ring sign, glucose content of the nasal fluid, Beta-trace protein test, Beta2-transferrin test. To eliminate this risk of meningitis, when a CSF leak is discovered, the defect must be closed surgically. The challenge is to determine the exact location of the defect, mainly in cases of spontaneous CSF fistulas. The imagistic examination consists of CT scans and MRI tests. The gold standard for detecting CSF leakage is still intrathecal injection of fluorescein with endoscopic localization of the dural defect. This paper aims to analyze a staining test, using Lugol solution, to detect the location of the CSF fistula. The Lugol staining test that we proposed is quick, cheap, it does not produce a toxic reaction, excepting the Iodine allergic patients, and it can be used to detect the location of the skull base defect and the CSF leak.

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Reconstruction After Posterior Cranial Fossa Surgery—Case Report of Application of a Synthetic Tissue Sealant to Augment Dural Closure

US Neurology ◽

10.17925/usn.2010.05.02.85 ◽

2010 ◽

Vol 05 (02) ◽

pp. 85

Author(s):

Nicholas D Coppa ◽

Johnny B Delashaw Jr ◽

◽

Keyword(s):

Case Report ◽

Patient Outcomes ◽

Posterior Cranial Fossa ◽

Csf Leak ◽

Dural Closure ◽

Wound Breakdown ◽

Csf Leakage ◽

Tissue Sealant ◽

Cranial Fossa ◽

Csf Leaks

Cerebrospinal fluid (CSF) leakage following cranial surgery is a well-described and potentially devastating complication, particularly in posteriorcranial fossa surgery. If untreated, a persistent CSF leak can evolve into wound breakdown, a surgical-site infection, and meningitis. Themorbidity of a complication following a cranial operation is harmful to the patient. Additionally, complications are a source of elevated medicalcosts. Numerous reconstruction strategies have been developed to thwart the ill effects of CSF leaks on patient outcomes and healthcarefinances. This case report illustrates the method employed at our institution to repair posterior fossa defects following surgery in thecerebellopontine angle.

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Use of a Novel Absorbable Hydrogel for Augmentation of Dural Repair: Results of a Preliminary Clinical Study

Operative Neurosurgery ◽

10.1227/01.neu.0000164384.05351.59 ◽

2005 ◽

Vol 57 (suppl_1) ◽

pp. 146-151 ◽

Cited By ~ 41

Author(s):

Jeroen D. Boogaarts ◽

J. André Grotenhuis ◽

Ronald H.M.A. Bartels ◽

Tjemme Beems

Keyword(s):

Valsalva Maneuver ◽

Csf Leak ◽

Consecutive Series ◽

Standard Laboratory ◽

Dural Repair ◽

Dural Closure ◽

Csf Leakage ◽

And Performance ◽

Csf Leaks ◽

Repair Techniques

Abstract OBJECTIVE: To evaluate the safety and performance of a synthetic dural sealant as an adjunct to standard surgical dural repair techniques to prevent cerebrospinal fluid (CSF) leakage. METHODS: This study was designed as a prospective, nonrandomized, single-center clinical trial. The dural sealant is a synthetic absorbable hydrogel. Consecutive series of patients scheduled for elective cranial and intradural spinal surgery were included until a total of 50 applications were achieved. It was used primarily as an adjunct to ensure watertight dural closure. The end point was defined as no leak with the Valsalva maneuver after dural sealant application. The patients were followed up for 3 months after surgery to check for CSF leakage, standard laboratory and neurological examinations, and possible adverse advents. RESULTS: Of the 49 patients, 46 were included and treated with the dural sealant because of spontaneous leak (n = 34; 69%) or leak after the Valsalva maneuver (n = 12; 25%). There was no leak in the other patients (n = 3; 6%). After application of the dural sealant, there was no leak in all 46 patients (100%). Of the 46 patients included, there was one case of overt CSF leak. One patient had a pseudomeningocele. There were no adverse events other than those related to the disease or to the surgical procedure itself. CONCLUSION: The dural sealant, a synthetic absorbable hydrogel, is a useful adjunct to achieve watertight dural closure. Application resulted in 100% closure of intraoperative CSF leaks. There are no evident adverse effects.

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Correlation of spontaneous and traumatic anterior skull base CSF leak flow rates with fluid pattern on early, delayed, and subtraction volumetric extended echo train T2-weighted MRI

Journal of Neurosurgery ◽

10.3171/2019.10.jns192500 ◽

2019 ◽

pp. 1-9 ◽

Cited By ~ 3

Author(s):

John W. Rutland ◽

Satish Govindaraj ◽

Corey M. Gill ◽

Michael Shohet ◽

Alfred M. C. Iloreta ◽

...

Keyword(s):

Skull Base ◽

Flow Rate ◽

High Flow ◽

Anterior Skull Base ◽

Low Flow ◽

Csf Leak ◽

Dural Defect ◽

Csf Leakage ◽

Csf Leaks ◽

Volumetric Segmentation

OBJECTIVECSF leakage is a potentially fatal condition that may result when a skull base dural defect permits CSF communication between the cranial vault and sinonasal cavities. Flow rate is an important property of CSF leaks that can contribute to surgical decision-making and predispose patients to complications and inferior outcomes. Noninvasive preoperative prediction of the leak rate is challenging with traditional diagnostic tools. The present study compares fluid configurations on early and late volumetric extended echo train T2-weighted MRI by using image tracings and sequence subtraction as a novel method of quantifying CSF flow rate, and it correlates radiological results with intraoperative findings and clinical outcomes.METHODSA total of 45 patients met inclusion criteria for this study and underwent 3-T MRI. Imaging sequences included two identical CUBE T2 (vendor trade name for volumetric extended echo train T2) acquisitions at the beginning and end of the scanning session, approximately 45 minutes apart. Twenty-five patients were confirmed to have definitive spontaneous or traumatic anterior skull base CSF leaks. Semiautomated volumetric segmentation of CSF intensity was performed on both CUBE data sets by using 3D-Slicer software, and volumes were subtracted to obtain accumulated CSF volume. These imaging-derived fluid accumulations were correlated with high- or low-flow states, as well as ultimate treatment outcomes including recurrences.RESULTSOf the 45 patients, 25 (55.6%) had definitive evidence of CSF leakage, and 22 (88%) of these underwent surgical repair. Patients with high-flow CSF leaks had higher early (4.058 cm3 vs 0.982 cm3, p = 0.04), late (4.58 cm3 vs 1.096 cm3, p = 0.04), and accumulated (0.53 cm3 vs 0.11 cm3, p = 0.01) fluid volume measurements than patients with low-flow leaks. The 5 (22.7%) patients who exhibited postoperative CSF leak recurrence had significantly greater early (6.30 cm3 vs 1.23 cm3, p = 0.008) and late (6.87 cm3 vs 1.45 cm3, p = 0.008) volumes. Accumulated volume was not significantly greater in patients with leak recurrence (0.58 cm3 vs 0.22 cm3, p = 0.07). Early, late, and accumulated volumes were significantly correlated with postoperative hospital stay as well as duration of postoperative lumbar drain placement (p < 0.05 for all measures).CONCLUSIONSHigh-resolution CUBE T2 MRI, coupled with precise volumetric segmentation and subtraction of sinonasal hyperintensity, not only demonstrated predictive value in differentiating low- and high-flow CSF leaks, but also correlated with postoperative complications such as leak recurrence. These findings may be useful in the clinical workup and neurosurgical management of patients with skull base CSF leaks.

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Primary Dural Closure for Retrosigmoid Approaches

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1607455 ◽

2017 ◽

Vol 79 (04) ◽

pp. 330-334 ◽

Cited By ~ 1

Author(s):

Garrett Venable ◽

Mallory Roberts ◽

Ryan Lee ◽

L. Michael

Keyword(s):

Posterior Fossa ◽

Primary Closure ◽

Chart Review ◽

Tumor Resection ◽

Retrospective Chart Review ◽

Csf Leak ◽

Dural Defect ◽

Dural Closure ◽

Lesion Type ◽

Csf Leaks

Object Primary closure of posterior fossa dura can be challenging, and postoperative cerebrospinal fluid (CSF) leaks continue to represent a common complication of the retrosigmoid approach. We describe a simple technique to allow for primary closure of the dura following retrosigmoid approaches. The incidence of CSF leaks using this method is reported. Methods A retrospective chart review was conducted on all cases of retrosigmoid craniotomies performed by the senior surgeon from February 2009 to February 2015. The primary outcome was development of postoperative CSF leak or pseudomeningocele. Length of stay, lesion type, and other surgical complications were also reported. Results Eighty-six patients underwent a retrosigmoid craniotomy during the study period. The most common indications for retrosigmoid craniotomy were microvascular decompression (58%) and tumor resection (36%). No allo- or autografts to repair the dural defect were needed, and no lumbar drains were used. No patients developed CSF otorrhea, rhinorrhea, or incisional leak postoperatively. Conclusion Primary dural closure is possible in retrosigmoid approaches without the use of allo- or autografts and may prevent postoperative CSF leaks when combined with other posterior fossa closure techniques. Careful attention to the handling of the dural flap is necessary to achieve this.

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Dural closure for the treatment of superficial siderosis

Journal of Neurosurgery Spine ◽

10.3171/2013.1.spine12649 ◽

2013 ◽

Vol 18 (4) ◽

pp. 388-393 ◽

Cited By ~ 20

Author(s):

Satoru Egawa ◽

Toshitaka Yoshii ◽

Kyohei Sakaki ◽

Hiroyuki Inose ◽

Tsuyoshi Kato ◽

...

Keyword(s):

Present Report ◽

Fluid Collection ◽

Clinical Manifestations ◽

Fat Grafting ◽

Neurological Deficits ◽

Superficial Siderosis ◽

Dural Defect ◽

Dural Closure ◽

Csf Leakage ◽

Dural Defects

Superficial siderosis (SS) of the CNS is a rare disease caused by repeated hemorrhages in the subarachnoid space. The subsequent deposition of hemosiderin in the brain and spinal cord leads to the progression of neurological deficits. The causes of bleeding include prior intradural surgery, carcinoma, arteriovenous malformation, nerve root avulsion, and dural abnormality. Recently, surgical treatment of SS associated with dural defect has been reported. The authors of the present report describe 2 surgically treated SS cases and review the literature on surgically treated SS. The patients had dural defects with fluid-filled collections in the spinal canal. In both cases, the dural defects were successfully closed, and the fluid collection was resolved postoperatively. In one case, the neurological symptoms did not progress postoperatively. In the other case, the patient had long history of SS, and the clinical manifestations partially deteriorated after surgery, despite the successful dural closure. In previously reported surgically treated cases, the dural defects were closed by sutures, patches, fibrin glue, or muscle/fat grafting. Regardless of the closing method, dural defect closure has been shown to stop CSF leakage and subarachnoid hemorrhaging. Successfully repairing the defect can halt the disease progression in most cases and may improve the symptoms that are associated with CSF hypovolemia. However, the effect of the dural closure may be limited in patients with long histories of SS because of the irreversibility of the neural tissue damage caused by hemosiderin deposition. In patients with SS, it is important to diagnose and repair the dural defect early to minimize the neurological impairments that are associated with dural defects.

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