Histological effects of fibrin glue on nervous tissue: a safety study in rats

Alaska Pollock-derived Gelatin Sealant has Higher Sealing Strength than, and Comparable Biocompatibility with, Fibrin Sealant in Porcine and Rat Dural Injury Models

STUDY DESIGN

Burst strength study in porcine dural models and functional and histological study in rat dural models.

OBJECTIVE

This study aimed to investigate the sealing strength and biocompatibility of Alaska pollock-derived gelatin (ApGltn) and fibrin sealants in disrupted dural injuries.

SUMMARY OF BACKGROUND DATA

Disruption of the dura mater occurs during spine surgery, leading to cerebrospinal fluid leakage. Fibrin sealant is usually applied to ruptured sites; however, it lacks sealing strength. A novel biocompatible sealant composed of ApGltn was recently demonstrated to have good burst strength and biocompatibility in the porcine aorta.

METHODS

Ten porcine dura maters with central holes were covered with ApGltn and fibrin sealants (five samples per group). The maximum burst strength of each sealant was measured, and histological examination was performed after burst testing. Twenty-seven dura maters of male Wistar rats were used for functional and histopathological evaluations. The rats were treated with three surgical interventions: defect + ApGltn sealant; defect + fibrin sealant; defect alone (nine rats per group). Macroscopic confirmation of the sealant, hindlimb motor function analysis, and histopathological examination were performed at two, four, and eight weeks after the procedure.

RESULTS

The maximum burst strength of the ApGltn sealant was ~4.4 times higher than that of the fibrin sealant (68.1±12.1 vs . 15.6±8.7 mmHg; P <0.001). Histological examination confirmed that the ApGltn sealant showed tight adhesion to the dural surface, whereas a gap was observed between the fibrin sealant and the dura mater. In the rat model, the ApGltn sealant resulted in spinal function and dural histological findings similar to those of the fibrin sealant.

CONCLUSION

The ApGltn sealant had a higher sealing strength than, and comparable effect on dura regeneration with, the fibrin sealant.

Conditioning electrical stimulation fails to enhance sympathetic axon regeneration

Peripheral nerve injuries are common, and there is a critical need for the development of novel therapeutics to complement surgical repair. Conditioning electrical stimulation (CES) is a novel variation to the well-studied perioperative electrical stimulation, both of which have displayed success in enhancing the regeneration of motor and sensory axons in an injured peripheral nerve. CES is a clinically attractive alternative not only because of its ability to be performed at the bedside prior to a scheduled nerve repair surgery, but it has also been shown to be superior to perioperative electrical stimulation in the enhancement of motor and sensory regeneration. However, the effects of CES on sympathetic regeneration are unknown. Therefore, we tested the effects of two clinically relevant CES paradigms on sympathetic axon regeneration and distal target reinnervation. Because of the long history of evidence for the enhancement of motor and sensory axons in response to electrical stimulation, we hypothesize that CES will also enhance sympathetic axon regeneration. Our results indicate that the growth of sympathetic axons is acutely inhibited by CES; however, at a longer survival time point post-injury, there is no difference between sham CES and the CES groups. There has been evidence to suggest that the growth of sympathetic axons is inhibited by a conditioning lesion, and that sympathetic axons may respond to electrical stimulation by sprouting rather than elongation. Our data indicate that sympathetic axons may retain some regenerative ability after CES, but no enhancement is exhibited, which may be accounted for by the inability of the current clinically relevant electrical stimulation paradigm to recruit the small-caliber sympathetic axons into activity. Further studies will be needed to optimize electrical stimulation parameters in order to enhance the regeneration of all neuron types.

Effectiveness of the Fibrinogen-Thrombin-Impregnated Collagen Patch in the Prevention of Postoperative Complications after Parotidectomy: A Single-Blinded, Randomized Controlled Study

We investigated whether a fibrinogen-thrombin collagen sponge patch reduces postoperative complications of parotid gland surgery. This single-blinded, randomized controlled study included 165 patients who underwent parotid surgery for benign tumors (2018–2019) at a tertiary center. Primary outcomes were postoperative drain amount, days until drain removal, and discharge. Patients were scheduled for follow-up at 1 and 4 weeks, and 3 months after surgery. Complications including surgical site infection, pain, seroma, sialocele, salivary fistula, facial nerve palsy, Frey’s syndrome with subjective symptoms, and facial asymmetry were analyzed. After identifying confounding variables, multivariate approaches were used. Histologic analysis was performed in a mouse model of salivary gland surgery. In total, 162 patients (77, fibrinogen-thrombin collagen patch group; 85, controls) were included, with no significant between-group differences other than resected tissue. Among postoperative total drain amount and days until drain removal and discharge, the only postoperative total drain was significantly lower in the patch group than in the control group in the adjusted model. Additionally, although validation through robust trials with longer follow-up is needed, we found the potential benefit of the fibrinogen patch on Frey’s syndrome and facial asymmetry. In conclusion, fibrinogen-thrombin-impregnated collagen patches in parotidectomy can reduce postoperative drainage and improve outcomes.

Case Report: Internal Carotid Artery Thrombosis: A Rare Complication After Fibrin Glue Injection for Cavernous Sinus Hemostasis

Background: Fibrin glue injection within the cavernous sinus (CS) is a demonstrably safe and simple technique to control venous bleeding with a low complication rate. However, this technique does have inherent risks. We illustrate 2 cases of internal carotid artery (ICA) thrombosis after fibrin glue injection in the CS for hemostasis.

Methods: After encountering this complication recently, we conducted a retrospective review of the surgical database of 2 senior neurosurgeons who specialize in cerebrovascular and skull base surgery to identify patients with any complications associated with the use of fibrin glue injection for hemostasis. Approval was given by respective institutional review boards, and patient consent was obtained.

Results: Of more than 10,000 microsurgery procedures performed by 2 senior neurosurgeons with a combined experience of 40 years, including procedures for aneurysms and skull base tumors, 2 cases were identified involving ICA thrombosis after fibrin glue injection in the CS for hemostasis. Both cases involved severe ischemic complications as a result of the ICA thrombosis. In this article, we present their clinical presentation, characteristics, management, and outcomes.

Conclusion: Direct injection of fibrin glue into the CS for hemostasis can effectively control venous bleeding and facilitate complex dissections. However, it can be associated with ICA thrombosis, with subsequent serious ischemia and poor prognosis. Although this complication appears to be rare, increased awareness of this problem should temper the routine use of fibrin glue in anterior clinoidectomy and transcavernous approaches.

Efficacy and histopathological effects of self-assembling peptides RADA16 and IEIK13 in neurosurgical hemostasis

There is a continued need for effective hemostatic agents that are safe for neurosurgical use. Self-assembling peptide hydrogels have been suggested as novel hemostatic agents. They offer some advantages for neurosurgical hemostasis (e.g., transparency), but their efficacy and safety for neurosurgery has not been established. In this paper, the efficacy and safety of two self-assembling peptides, RADA16 and IEIK13, are explored for hemostasis of oozing bleeding on the rat cerebral cortex (n=56). Chronic safety was evaluated by neuropathological evaluation at one, four, and twelve weeks after craniotomy (n=32). An inactive control and oxidized cellulose served as comparators. Mean time-to-hemostasis was significantly shorter for RADA16 and IEIK13 compared to controls, while safety evaluation yielded similar results. Histopathological response consisted primarily of macrophage infiltration at the lesion site in all groups. This study confirms the hemostatic potential and safety of RADA16 and IEIK13 for hemostasis in the rat brain.

Asparagine Endopeptidase (δ Secretase), an Enzyme Implicated in Alzheimer's Disease Pathology, Is an Inhibitor of Axon Regeneration in Peripheral Nerves

Asparagine endopeptidase (AEP) is a lysosomal protease implicated in the pathology of Alzheimer’s disease (AD). It is known to cleave the axonal microtubule associated protein, Tau, and amyloid precursor protein (APP), both of which might impede axon regeneration following peripheral nerve injury (PNI). Active AEP, AEP-cleaved fragments of Tau (Tau N368), and APP (APP N585) were found in injured peripheral nerves. In AEP null mice, elongation of regenerating axons after sciatic nerve transection and repair was increased relative to wild-type (WT) controls. Compound muscle action potentials (M responses) were restored in reinnervated muscles twice as fast after injury in AEP knock-out (KO) mice as WT controls. Neurite elongation in cultures of adult dorsal root ganglion (DRG) neurons derived from AEP KO mice was increased significantly relative to cultures from WT controls. In AEP KO mice exposed to 1 h of 20-Hz electrical stimulation (ES) at the time of nerve injury, no further enhancement of axon regeneration was observed. These findings support inhibition of AEP as a therapeutic target to enhance axon regeneration after PNI.

Early regeneration of axons following peripheral nerve injury is enhanced if p75NTR is eliminated from the surrounding pathway

The common neurotrophin receptor, p75^NTR , has been proposed to be an inhibitor of axon regeneration after peripheral nerve injury, but whether this effect is on the regenerating axons, immune cells migrating into the injury site, or cells in the pathway surrounding the axons is not clear. Cut nerves in mice expressing fluorescent proteins in axons were repaired with grafts from non-fluorescent hosts to study axon elongation when p75^NTR was eliminated separately from axons and immune cells in the proximal stump of cut nerves, from cells in the regeneration pathway, or both. Two weeks later, axons from wild type mice regenerating into grafts devoid of p75^NTR had elongated more than twice as far as axons in grafts from wild type mice. No enhancement of regeneration of axons in p75^NTR knockout mice was observed, whether nerves were repaired with grafts from wild type mice or from p75^NTR knockout mice. To evaluate whether inhibition of p75^NTR could be used to improve regeneration, nerves in wild type mice repaired without grafts were exposed to a specific inhibitor of the p75^NTR receptor, LM11A-31, at the time of nerve repair. This local blockade of p75^NTR resulted in successful regeneration of axons of nearly three times as many motoneurons and reinnervation of twice as many muscle fibers by regenerating motor axons as untreated controls. Expression of p75^NTR surrounding regenerating axons contributes to poor regeneration during the first 2 weeks after peripheral nerve injury. Inhibition of p75^NTR might be a therapeutic target for treatments of peripheral nerve injuries.

The Val66Met BDNF Polymorphism and Peripheral Nerve Injury: Enhanced Regeneration in Mouse Met-Carriers Is Not Further Improved With Activity-Dependent Treatment

Activity-dependent treatments to enhance peripheral nerve regeneration after injury have shown great promise, and clinical trials implementing them have begun. Success of these treatments requires activity-dependent release of brain-derived neurotrophic factor (BDNF). A single nucleotide polymorphism (SNP) in the bdnf gene known as Val66Met, which is found in nearly one third of the human population, results in defective activity-dependent BDNF secretion and could impact the effectiveness of these therapies. Here, we used a mouse model of this SNP to test the efficacy of treadmill exercise in enhancing axon regeneration in animals both heterozygous (V/M) and homozygous (M/M) for the SNP. Axon regeneration was studied 4 weeks after complete transection and repair of the sciatic nerve in both male and female animals, using both electrophysiological and histological outcome measures. Regeneration was enhanced significantly without treatment in V/M mice, compared with wild type (V/V) controls. Unlike V/V mice, treatment of both V/M and M/M mice with treadmill exercise did not result in enhanced regeneration. These results were recapitulated in vitro using dissociated neurons containing the light-sensitive cation channel, channelrhodopsin. Three days after plating, neurites of neurons from V/M and M/M mice were longer than those of V/V neurons. In neurons from V/V mice, but not those from V/M or M/M animals, longer neurites were found after optogenetic stimulation. Taken together, Met-carriers possess an intrinsically greater capacity to regenerate axons in peripheral nerves, but this cannot be enhanced further by activity-dependent treatments.

Bioadhesives for internal medical applications: A review

Bioadhesives such as tissue adhesives, hemostatic agents, and tissue sealants have gained increasing popularity in different areas of clinical operations during the last three decades. Bioadhesives can be categorized into internal and external ones according to their application conditions. External bioadhesives are generally applied in topical medications such as wound closure and epidermal grafting. Internal bioadhesives are mainly used in intracorporal conditions with direct contact to internal environment including tissues, organs and body fluids, such as chronic organ leak repair and bleeding complication reduction. This review focuses on internal bioadhesives that, in contrast with external bioadhesives, emphasize much more on biocompatibility and adhesive ability to wet surfaces rather than on gluing time and intensity. The crosslinking mechanisms of present internal bioadhesives can be generally classified as follows: 1) chemical conjugation between reactive groups; 2) free radical polymerization by light or redox initiation; 3) biological or biochemical coupling with specificity; and 4) biomimetic adhesion inspired from natural phenomena. In this review, bioadhesive products of each class are summarized and discussed by comparing their designs, features, and applications as well as their prospects for future development.

STATEMENT OF SIGNIFICANCE

Despite the emergence of numerous novel bioadhesive formulations in recent years, thus far, the classification of internal and external bioadhesives has not been well defined and universally acknowledged. Many of the formulations have been proposed for treatment of several diseases even though they are not applicable for such conditions. This is because of the lack of a systematic standard or evaluation protocol during the development of a new adhesive product. In this review, the definition of internal and external bioadhesives is given for the first time, and with a focus on internal bioadhesives, the criteria of an ideal internal bioadhesive are adequately discussed; this is followed by the review of recently developed internal bioadhesives based on different gluing mechanisms.

Revision Microvascular Decompression for Trigeminal Neuralgia and Hemifacial Spasm: Factors Associated with Surgical Failure

Objective  To investigate risk factors for symptom recurrence in patients requiring a revision microvascular decompression (MVD) for trigeminal neuralgia (TN) or hemifacial spasm (HFS). Design  Retrospective review of a prospectively maintained database. Participants  Seventeen consecutive patients undergoing revision MVD at our institution between January 1993 and September 2017. Main Outcome Measures  The incidence and causes for revision MVDs were recorded. Response to revision MVD for TN was tracked using the Barrow Neurological Institute (BNI) grading scale. Response to revision MVD for HFS was graded as "no improvement," "some relief," or "complete resolution" of symptoms. Results  Revision MVD rate for the senior author across all MVDs performed in this period was 1.9% for TN and 9.3% for HFS. Initial MVD failure was primarily caused by active inflammation and/or scarring and adhesions in 5/17 patients, malposition/slippage of Teflon in 3/17 patients, and insufficient Teflon in 1/17 patients. Without other factors, a new site of neurovascular conflict was identified in 4/17 patients, while the same site of neurovascular conflict was found in 3/17 patients. No cause could be identified in 1/17 patients. Scarring was found primarily in the TN group and was associated with symptom persistence. Conclusion  Revision MVD for recurrent TN and HFS is an effective procedure offering the prospect of a complete cure. Proper Teflon use is crucial for surgical success. Scarring after initial MVD is a negative prognostic factor requiring destructive treatment consideration. Although morbidity rates were slightly increased with revision versus original MVDs, the complications were non-disabling and resolved over time.

Optogenetically enhanced axon regeneration: motor versus sensory neuron-specific stimulation

Brief neuronal activation in injured peripheral nerves is both necessary and sufficient to enhance motor axon regeneration, and this effect is specific to the activated motoneurons. It is less clear whether sensory neurons respond in a similar manner to neuronal activation following peripheral axotomy. Further, it is unknown to what extent enhancement of axon regeneration with increased neuronal activity relies on a reflexive interaction within the spinal circuitry. We used mouse genetics and optical tools to evaluate the precision and selectivity of system-specific neuronal activation to enhance axon regeneration in a mixed nerve. We evaluated sensory and motor axon regeneration in two different mouse models expressing the light-sensitive cation channel, channelrhodopsin (ChR2). We selectively activated either sensory or motor axons using light stimulation combined with transection and repair of the sciatic nerve. Regardless of genotype, the number of ChR2-positive neurons whose axons had regenerated successfully was greater following system-specific optical treatment, with no effect on the number of ChR2-negative neurons (whether motor or sensory neurons). We conclude that acute system-specific neuronal activation is sufficient to enhance both motor and sensory axon regeneration. This regeneration-enhancing effect is likely cell autonomous.

Microtubule stabilization promoted axonal regeneration and functional recovery after spinal root avulsion

A spinal root avulsion injury disconnects spinal roots with the spinal cord. The rampant motoneuron death, inhibitory CNS/PNS transitional zone (TZ) for axonal regrowth and limited regeneration speed together lead to motor dysfunction. Microtubules rearrange to assemble a new growth cone and disorganized microtubules underline regeneration failure. It has been shown that microtubule-stabilizing drug, Epothilone B, enhanced axonal regeneration and attenuated fibrotic scaring after spinal cord injury. Here, we are reporting that after spinal root avulsion+ re-implantation in adult rats, EpoB treatment improved motor functional recovery and potentiated electrical responses of motor units. It facilitated axons to cross the TZ and promoted more and bigger axons in the peripheral nerve. Neuromuscular junctions were reformed with better preserved postsynaptic structure, and muscle atrophy was prevented by EpoB administration. Our study showed that EpoB was a promising therapy for promoting axonal regeneration after peripheral nerve injury.

Estrogen signaling is necessary for exercise-mediated enhancement of motoneuron participation in axon regeneration after peripheral nerve injury in mice

Thousands of people each year suffer from peripheral nerve injury. Treatment options are limited, and recovery is often incomplete. Treadmill exercise can enhance nerve regeneration; however, this appears to occur in a sex-dependent manner. Females respond best to short duration, high speed interval training; whereas, males respond best to slower, continuous training. Previous studies have shown a role for testosterone in this process, but the role of estrogen is unknown. To evaluate the role of estrogen signaling in treadmill exercise, we blocked estrogen receptor (ER) signaling during treadmill exercise in males and female wild type mice. The right common fibular (CF) branch of the sciatic nerve was cut and repaired with fibrin glue that contained the ER antagonist ICI 182,780. Estradiol-filled or blank Silastic capsules were implanted subcutaneously at the time of nerve transection. Starting three days post-transection, exercised mice received treadmill training using the paradigm appropriate to their sex 5 days a week for 2 weeks. Fourteen days after the initial nerve transection, motoneurons whose axons had regenerated at least 1.5 mm distal to the original cut sites were labeled with a retrograde tracer. Regeneration was quantified by counting the number of fluorescent labeled motoneurons in the lumbar region of the spinal cord. Both treadmill training and estradiol administration increased the number of motoneurons participating in axon regeneration, but these effects were blocked by ER antagonist treatment. Estrogen signaling is important for the enhancing effects of treadmill exercise on motoneuron participation after peripheral nerve cut. © 2017 Wiley Periodicals, Inc. Develop Neurobiol 77: 1133-1143, 2017.

Effect of Fibrin Glue Injection Into the Cavernous Sinus for Hemostasis During Transcavernous Surgery on the Cerebral Venous Draining System

BACKGROUND: The extradural temporopolar transcavernous approach can be used to treat central skull base pathologies, but control of bleeding from the opened cavernous sinus is essential. Oxidized cellulose cotton packing and fibrin glue injection can be used, but the effect on the postoperative venous draining pattern remains unclear.

OBJECTIVE: To investigate changes in the venous drainage pattern immediately after transcavernous surgery with and without fibrin glue injection into the bleeding cavernous sinus.

METHODS: A total of 82 patients treated via the transcavernous approach were retrospectively divided into 2 groups based on the hemostasis methods. Both pre- and postoperative angiography and/or 3-dimensional computed tomography venography were available for 24 patients in the cotton packing group and 12 patients in the fibrin glue group.

RESULTS: Postoperative change in the venous draining pattern was observed in 5 of the 24 patients in the cotton packing group and in 3 of the 12 patients in the fibrin glue group. One of the 82 patients showed postoperative brain swelling due to obstruction of the sphenoparietal sinus. The volume of injected fibrin glue ranged from 0.5 to 2.5 mL (mean, 1.1 ± 0.5 mL), but none of the patients had brain swelling.

CONCLUSION: Direct fibrin glue injection into the opened cavernous sinus is relatively safe, but a change in the venous draining pattern occurs in 25% of patients. The study indicates the potential danger of the change in the venous draining pattern and recommends limiting the injection volume of fibrin glue in transcavernous surgery to avoid complications related to venous congestion.

Multiple uses of fibrin sealant for nervous system treatment following injury and disease

Lesions to the nervous system often produce hemorrhage and tissue loss that are difficult, if not impossible, to repair. Therefore, scar formation, inflammation and cavitation take place, expanding the lesion epicenter. This significantly worsens the patient conditions and impairment, increasing neuronal loss and glial reaction, which in turn further decreases the chances of a positive outcome. The possibility of using hemostatic substances that also function as a scaffold, such as the fibrin sealant, reduces surgical time and improve postoperative recovery. To date, several studies have demonstrated that human blood derived fibrin sealant produces positive effects in different interventions, becoming an efficient alternative to suturing. To provide an alternative to homologous fibrin sealants, the Center for the Study of Venoms and Venomous Animals (CEVAP, Brazil) has proposed a new bioproduct composed of certified animal components, including a thrombin-like enzyme obtained from snake venom and bubaline fibrinogen. Thus, the present review brings up to date literature assessment on the use of fibrin sealant for nervous system repair and positions the new heterologous bioproduct from CEVAP as an alternative to the commercial counterparts. In this way, clinical and pre-clinical data are discussed in different topics, ranging from central nervous system to peripheral nervous system applications, specifying positive results as well as future enhancements that are necessary for improving the use of fibrin sealant therapy.

Direct Spinal Ventral Root Repair following Avulsion: Effectiveness of a New Heterologous Fibrin Sealant on Motoneuron Survival and Regeneration

Axonal injuries at the interface between central and peripheral nervous system, such as ventral root avulsion (VRA), induce important degenerative processes, mostly resulting in neuronal and motor function loss. In the present work, we have compared two different fibrin sealants, one derived from human blood and another derived from animal blood and Crotalus durissus terrificus venom, as a promising treatment for this type of injury. Lewis rats were submitted to VRA (L4–L6) and had the avulsed roots reimplanted to the surface of the spinal cord, with the aid of fibrin sealant. The spinal cords were processed to evaluate neuronal survival, synaptic stability, and glial reactivity, 4 and 12 weeks after lesion. Sciatic nerves were processed to investigate Schwann cell activity by p75^NTR expression (4 weeks after surgery) and to count myelinated axons and morphometric evaluation (12 weeks after surgery). Walking track test was used to evaluate gait recovery, up to 12 weeks. The results indicate that both fibrin sealants are similarly efficient. However, the snake-derived fibrin glue is a potentially safer alternative for being a biological and biodegradable product which does not contain human blood derivatives. Therefore, the venom glue can be a useful tool for the scientific community due to its advantages and variety of applications.

Long-Standing Motor and Sensory Recovery following Acute Fibrin Sealant Based Neonatal Sciatic Nerve Repair

Brachial plexus lesion results in loss of motor and sensory function, being more harmful in the neonate. Therefore, this study evaluated neuroprotection and regeneration after neonatal peripheral nerve coaptation with fibrin sealant. Thus, P2 neonatal Lewis rats were divided into three groups: AX: sciatic nerve axotomy (SNA) without treatment; AX+FS: SNA followed by end-to-end coaptation with fibrin sealant derived from snake venom; AX+CFS: SNA followed by end-to-end coaptation with commercial fibrin sealant. Results were analyzed 4, 8, and 12 weeks after lesion. Astrogliosis, microglial reaction, and synapse preservation were evaluated by immunohistochemistry. Neuronal survival, axonal regeneration, and ultrastructural changes at ventral spinal cord were also investigated. Sensory-motor recovery was behaviorally studied. Coaptation preserved synaptic covering on lesioned motoneurons and led to neuronal survival. Reactive gliosis and microglial reaction decreased in the same groups (AX+FS, AX+CFS) at 4 weeks. Regarding axonal regeneration, coaptation allowed recovery of greater number of myelinated fibers, with improved morphometric parameters. Preservation of inhibitory synaptic terminals was accompanied by significant improvement in the motor as well as in the nociceptive recovery. Overall, the present data suggest that acute repair of neonatal peripheral nerves with fibrin sealant results in neuroprotection and regeneration of motor and sensory axons.

Histopathological Effects of Fibrin Glue and Cyanoacrylate on the Maxillary Sinus

Objective

To compare the histopathological effects of fibrin glue (FbGl) and cyanoacrylate (CyAc) on the maxillary sinus mucosa.

Methods

Twenty rabbits were divided into two groups of 10, and surgical defects were created in the maxillary sinuses. The right maxillary sinus was treated with FbGl in one group and with CyAc in the other group. As a control, the left maxillary sinuses of all rabbits were treated with sterile saline solution. One rabbit treated with CyAc died during the study and was excluded. On postoperative day 21, all animals were sacrificed. Maxillary sinus mucosa samples were studied to determine the extent of inflammation and fibrosis, foreign body reaction, cilia loss, increased osteogenesis in bony structures under the mucosa, and loss of serous glands.

Results

The FbGl group differed significantly from the CyAc and control groups in terms of a high degree of inflammation (p<0.001), fibrosis (p<0.001), foreign body reaction (p<0.001), cilia loss (p<0.001), and serous gland loss (p<0.001). In terms of osteogenesis, there were no significant differences between the FbGl and CyAc groups (p=0.650), while there was a significant (p=0.002) difference between these two groups and the control group.

Conclusion

Histopathologically, CyAc had fewer side effects than FbGl. Further clinical studies are needed to demonstrate the validity of these results in humans.

Optically-Induced Neuronal Activity Is Sufficient to Promote Functional Motor Axon Regeneration In Vivo

Peripheral nerve injuries are common, and functional recovery is very poor. Beyond surgical repair of the nerve, there are currently no treatment options for these patients. In experimental models of nerve injury, interventions (such as exercise and electrical stimulation) that increase neuronal activity of the injured neurons effectively enhance axon regeneration. Here, we utilized optogenetics to determine whether increased activity alone is sufficient to promote motor axon regeneration. In thy-1-ChR2/YFP transgenic mice in which a subset of motoneurons express the light-sensitive cation channel, channelrhodopsin (ChR2), we activated axons in the sciatic nerve using blue light immediately prior to transection and surgical repair of the sciatic nerve. At four weeks post-injury, direct muscle EMG responses evoked with both optical and electrical stimuli as well as the ratio of these optical/electrical evoked EMG responses were significantly greater in mice that received optical treatment. Thus, significantly more ChR2+ axons successfully re-innervated the gastrocnemius muscle in mice that received optical treatment. Sections of the gastrocnemius muscles were reacted with antibodies to Synaptic Vesicle Protein 2 (SV2) to quantify the number of re-occupied motor endplates. The number of SV2+ endplates was greater in mice that received optical treatment. The number of retrogradely-labeled motoneurons following intramuscular injection of cholera toxin subunit B (conjugated to Alexa Fluor 555) was greater in mice that received optical treatment. Thus, the acute (1 hour), one-time optical treatment resulted in robust, long-lasting effects compared to untreated animals as well as untreated axons (ChR2-). We conclude that neuronal activation is sufficient to promote motor axon regeneration, and this regenerative effect is specific to the activated neurons.

Minimizing Collateral Brain Injury Using a Protective Layer of Fibrin Glue: Technical Note

BACKGROUND

Neurosurgical procedures expose the brain surface to a constant risk of collateral injury. We describe a technique where the brain surface is covered with a protective layer of fibrin glue and discuss its advantages.

METHODS

A thin layer of fibrin glue was applied on the brain surface after its exposure in 34 patients who underwent different craniotomies for tumoral and vascular lesions. Data of 35 more patients who underwent standard microsurgical technique were collected as a control group. Cortical and pial injuries were evaluated using an intraoperative visual scale. Eventual abnormal signals at the early postoperative T2-weighted fluid-attenuated inversion recovery (T2FLAIR) magnetic resonance imaging (MRI) sequences were evaluated in oncological patients.

RESULTS

Total pial injury was noted in 63% of cases where fibrin glue was not used. In cases where fibrin glue was applied, a significantly lower percentage of 26% (P < 0.01) had pial injuries. Only 9% had injuries in areas covered with fibrin glue (P < 0.0001). Early postoperative T2FLAIR MRI confirmed the differences of altered signal around the surgical field in the two populations.

CONCLUSION

We propose beside an appropriate and careful microsurgical technique the possible use of fibrin glue as alternative, safe, and helpful protection during complex microsurgical dissections. Its intrinsic features allow the neurosurgeon to minimize the cortical manipulation preventing minor collateral brain injury.

Fibrin sealant to prevent subdural electrode migration during intracranial electroencephalographic monitoring in a patient with a large arachnoid cyst

Ensuring a stable position of intracranial electrode grids with good proximity to the cortical surface can be a technical challenge in patients with complex anomalous cerebral anatomy. This report illustrates the use of fibrin sealant to secure subdural electrodes to concave cortical surfaces during intracranial electroencephalographic monitoring for localization-related medically intractable epilepsy in a patient with a large arachnoid cyst.

Antitumor effect of fibrin glue containing temozolomide against malignant glioma

Temozolomide (TMZ), used to treat glioblastoma and malignant glioma, induces autophagy, apoptosis and senescence in cancer cells. We investigated fibrin glue (FG) as a drug delivery system for the local administration of high-concentration TMZ aimed at preventing glioma recurrence. Our high-power liquid chromatography studies indicated that FG containing TMZ (TMZ-FG) manifested a sustained drug release potential. We prepared a subcutaneous tumor model by injecting groups of mice with three malignant glioma cell lines and examined the antitumor effect of TMZ-FG. We estimated the tumor volume and performed immunostaining and immunoblotting using antibodies to Ki-67, cleaved caspase 3, LC3 and p16. When FG sheets containing TMZ (TMZ-FGS) were inserted beneath the tumors, their growth was significantly suppressed. In mice treated with peroral TMZ plus TMZ-FGS the tumors tended to be smaller than in mice whose tumors were treated with TMZ-FGS or peroral TMZ alone. The TMZ-FGS induced autophagy, apoptosis and senescence in subcutaneous glioma tumor cells. To assess the safety of TMZ-FG for normal brain, we placed it directly on the brain of living mice and stained tissue sections obtained in the acute and chronic phase immunohistochemically. In both phases, TMZ-FG failed to severely damage normal brain tissue. TMZ-FG may represent a safe new drug delivery system with sustained drug release potential to treat malignant glioma.

Smaller, softer, lower-impedance electrodes for human neuroprosthesis: a pragmatic approach

Finding the most appropriate technology for building electrodes to be used for long term implants in humans is a challenging issue. What are the most appropriate technologies? How could one achieve robustness, stability, compatibility, efficacy, and versatility, for both recording and stimulation? There are no easy answers to these questions as even the most fundamental and apparently obvious factors to be taken into account, such as the necessary mechanical, electrical and biological properties, and their interplay, are under debate. We present here our approach along three fundamental parallel pathways: we reduced electrode invasiveness and size without impairing signal-to-noise ratio, we increased electrode active surface area by depositing nanostructured materials, and we protected the brain from direct contact with the electrode without compromising performance. Altogether, these results converge toward high-resolution ECoG arrays that are soft and adaptable to cortical folds, and have been proven to provide high spatial and temporal resolution. This method provides a piece of work which, in our view, makes several steps ahead in bringing such novel devices into clinical settings, opening new avenues in diagnostics of brain diseases, and neuroprosthetic applications.

Bio-inspired hybrid microelectrodes: a hybrid solution to improve long-term performance of chronic intracortical implants

The use of implants that allow chronic electrical stimulation and recording in the brain of human patients is currently limited by a series of events that cause the deterioration over time of both the electrode surface and the surrounding tissue. The main reason of failure is the tissue inflammatory reaction that eventually causes neuronal loss and glial encapsulation, resulting in a progressive increase of the electrode-electrolyte impedance. Here, we describe a new method to create bio-inspired electrodes to mimic the mechanical properties and biological composition of the host tissue. This combination has a great potential to increase the implant lifetime by reducing tissue reaction and improving electrical coupling. Our method implies coating the electrode with reprogrammed neural or glial cells encapsulated within a hydrogel layer. We chose fibrin as a hydrogel and primary hippocampal neurons or astrocytes from rat brain as cellular layer. We demonstrate that fibrin coating is highly biocompatible, forms uniform coatings of controllable thickness, does not alter the electrochemical properties of the microelectrode and allows good quality recordings. Moreover, it reduces the amount of host reactive astrocytes – over time – compared to a bare wire and is fully reabsorbed by the surrounding tissue within 7 days after implantation, avoiding the common problem of hydrogels swelling. Both astrocytes and neurons could be successfully grown onto the electrode surface within the fibrin hydrogel without altering the electrochemical properties of the microelectrode. This bio-hybrid device has therefore a good potential to improve the electrical integration at the neuron-electrode interface and support the long-term success of neural prostheses.

Motor recovery and synaptic preservation after ventral root avulsion and repair with a fibrin sealant derived from snake venom

BACKGROUND

Ventral root avulsion is an experimental model of proximal axonal injury at the central/peripheral nervous system interface that results in paralysis and poor clinical outcome after restorative surgery. Root reimplantation may decrease neuronal degeneration in such cases. We describe the use of a snake venom-derived fibrin sealant during surgical reconnection of avulsed roots at the spinal cord surface. The present work investigates the effects of this fibrin sealant on functional recovery, neuronal survival, synaptic plasticity, and glial reaction in the spinal motoneuron microenvironment after ventral root reimplantation.

METHODOLOGY/PRINCIPAL FINDINGS

Female Lewis rats (7 weeks old) were subjected to VRA and root replantation. The animals were divided into two groups: 1) avulsion only and 2) replanted roots with fibrin sealant derived from snake venom. Post-surgical motor performance was evaluated using the CatWalk system twice a week for 12 weeks. The rats were sacrificed 12 weeks after surgery, and their lumbar intumescences were processed for motoneuron counting and immunohistochemistry (GFAP, Iba-1 and synaptophysin antisera). Array based qRT-PCR was used to evaluate gene regulation of several neurotrophic factors and receptors as well as inflammatory related molecules. The results indicated that the root reimplantation with fibrin sealant enhanced motor recovery, preserved the synaptic covering of the motoneurons and improved neuronal survival. The replanted group did not show significant changes in microglial response compared to VRA-only. However, the astroglial reaction was significantly reduced in this group.

CONCLUSIONS/SIGNIFICANCE

In conclusion, the present data suggest that the repair of avulsed roots with snake venom fibrin glue at the exact point of detachment results in neuroprotection and preservation of the synaptic network at the microenvironment of the lesioned motoneurons. Also such procedure reduced the astroglial reaction and increased mRNA levels to neurotrophins and anti-inflammatory cytokines that may in turn, contribute to improving recovery of motor function.

Sex differences in the effectiveness of treadmill training in enhancing axon regeneration in injured peripheral nerves

Exercise in the form of daily treadmill training results in significant enhancement of axon regeneration following peripheral nerve injury. Because androgens are also linked to enhanced axon regeneration, we wanted to investigate whether sex differences in the effect of treadmill training might exist. The common fibular nerves of thy-1-YFP-H mice were cut and repaired with a graft of the same nerve from a strain-matched wild-type donor mouse. Animals were treated with one of two daily treadmill training paradigms: slow continuous walking for 1 h or four higher intensity intervals of 2 min duration separated by 5-min rest periods. Training was begun on the third day following nerve injury and continued 5 days per week for 2 weeks. Effects on regeneration were evaluated by measuring regenerating axon profile lengths in optical sections through the repair sites and grafts at the end of the training period. No sex differences were found in untrained control mice. Continuous training resulted in significant enhancement of axon regeneration only in males. No effect was found in females or in castrated males. Interval training was effective in enhancing axon regeneration only in females and not in intact males or castrated males. Untrained females treated with the aromatase inhibitor, anastrozole, had significant enhancement of axon regeneration without increasing serum testosterone levels. Two different mechanisms exist to promote axon regeneration in a sex-dependent manner. In males treadmill training uses testicular androgens. In females, a different cellular mechanism for the effect of treadmill training must exist.

Cooperative roles of BDNF expression in neurons and Schwann cells are modulated by exercise to facilitate nerve regeneration

After peripheral nerve injury, neurotrophins play a key role in the regeneration of damaged axons that can be augmented by exercise, although the distinct roles played by neurons and Schwann cells are unclear. In this study, we evaluated the requirement for the neurotrophin, brain-derived neurotrophic factor (BDNF), in neurons and Schwann cells for the regeneration of peripheral axons after injury. Common fibular or tibial nerves in thy-1-YFP-H mice were cut bilaterally and repaired using a graft of the same nerve from transgenic mice lacking BDNF in Schwann cells (BDNF(-/-)) or wild-type mice (WT). Two weeks postrepair, axonal regeneration into BDNF(-/-) grafts was markedly less than WT grafts, emphasizing the importance of Schwann cell BDNF. Nerve regeneration was enhanced by treadmill training posttransection, regardless of the BDNF content of the nerve graft. We further tested the hypothesis that training-induced increases in BDNF in neurons allow regenerating axons to overcome a lack of BDNF expression in cells in the pathway through which they regenerate. Nerves in mice lacking BDNF in YFP(+) neurons (SLICK) were cut and repaired with BDNF(-/-) and WT nerves. SLICK axons lacking BDNF did not regenerate into grafts lacking Schwann cell BDNF. Treadmill training could not rescue the regeneration into BDNF(-/-) grafts if the neurons also lacked BDNF. Both Schwann cell- and neuron-derived BDNF are thus important for axon regeneration in cut peripheral nerves.

Misdirection of regenerating axons and functional recovery following sciatic nerve injury in rats

Poor functional recovery found after peripheral nerve injury has been attributed to the misdirection of regenerating axons to reinnervate functionally inappropriate muscles. We applied brief electrical stimulation (ES) to the common fibular (CF) but not the tibial (Tib) nerve just prior to transection and repair of the entire rat sciatic nerve, to attempt to influence the misdirection of its regenerating axons. The specificity with which regenerating axons reinnervated appropriate targets was evaluated physiologically using compound muscle action potentials (M responses) evoked from stimulation of the two nerve branches above the injury site. Functional recovery was assayed using the timing of electromyography (EMG) activity recorded from the tibialis anterior (TA) and soleus (Sol) muscles during treadmill locomotion and kinematic analysis of hindlimb locomotor movements. Selective ES of the CF nerve resulted in restored M-responses at earlier times than in unstimulated controls in both TA and Sol muscles. Stimulated CF axons reinnervated inappropriate targets to a greater extent than unstimulated Tib axons. During locomotion, functional antagonist muscles, TA and Sol, were coactivated both in stimulated rats and in unstimulated but injured rats. Hindlimb kinematics in stimulated rats were comparable to untreated rats, but significantly different from intact controls. Selective ES promotes enhanced axon regeneration but does so with decreased fidelity of muscle reinnervation. Functional recovery is neither improved nor degraded, suggesting that compensatory changes in the outputs of the spinal circuits driving locomotion may occur irrespective of the extent of misdirection of regenerating axons in the periphery.

Investigation of the material properties of alginate for the development of hydrogel repair of dura mater

The collagenous dura mater isolates the brain from the external environment and requires a secure closure following invasive neurosurgery. This is typically accomplished by approximation of the dura mater via sutures and adhesives. In selected cases, however, large portions of dura mater require excision, necessitating a tissue replacement patch. The mild reaction conditions and long-term biocompatibility of alginate evince strong candidacy for these applications. This study investigates the potential of diffusion and internally gelled alginates for these applications. Specifically, we quantified the viscosity, gel rate, syneresis level, compressive strength, compressive modulus, complex modulus and loss angle in the context of dura mater repair. The ideal sealant would have a rapid cross-link speed, while the ideal dura mater replacement would have a low level of syneresis. Both applications require a compressive modulus of 20-100 kPa and a complex modulus of 1-24 kPa. The data collected in this study suggests that the use of 1.95 wt% 43 mPa s alginate with 200 mM CaCl(2) is sufficient for approximating the dural membrane for closure alone or in conjunction with suture. Alternatively, the use of 1.95 wt% 43 mPa s alginate with 100 mM CaCO(3) is sufficient for tissue replacement in large dural defects.

Use of tissue glue to prevent collapse of the cortical mantle during and after cranial surgery in children: a technical note

INTRODUCTION

Young children with significant ventricular dilatation or large intracranial fluid spaces often have a very thin cortical mantle as a result of persistently raised intracranial pressure. This rim of cortex has a tendency to fall away from the dura into the cavity during and after intracranial surgery, due to the lack of support, once the pressure in the fluid cavity has been reduced. This can lead to tearing of cortical bridging veins and the formation of post-operative subdural haematomas.

METHODS

We describe a simple technique that attempts to prevent this phenomenon occurring using tissue glue. Once the craniotomy has been performed and the dura has been formally opened, tissue glue is applied to the underside of the dura around the edge of the wound, prior to corticotomy.

RESULTS AND CONCLUSION

This results in the cortical mantle adhering to the undersurface of the dura and prevents the mantle from falling into the cavity either during the procedure or post-operatively.

Biodegradable fibrin conduit promotes long-term regeneration after peripheral nerve injury in adult rats

Peripheral nerve injuries are often associated with loss of nerve tissue and require autologous nerve grafts to provide a physical substrate for axonal growth. Biosynthetic neural conduits could be an alternative treatment strategy in such injuries. The present study investigates the long-term effects of a tubular fibrin conduit on neuronal regeneration, axonal sprouting and recovery of muscle weight following peripheral nerve injury and repair in adult rats. Sciatic axotomy was performed proximally in the thigh to create a 10-mm gap between the nerve stumps. The injury gap was bridged by using a 14-mm-long fibrin glue conduit, entubulating 2 mm of the nerve stump at each end. A reversed autologous nerve graft was used as a control. The regenerative response from sensory and motor neurones was evaluated following retrograde labelling with Fast Blue fluorescent tracer. In control experiments, at 16 weeks following peripheral nerve grafting, 5184 (±574 standard error of mean (SEM)) sensory dorsal root ganglion neurones and 1001 (±37 SEM) spinal motor neurones regenerated across the distal nerve-graft interface. The fibrin conduit promoted regeneration of 60% of sensory neurones and 52% of motor neurones when compared to the control group. The total number of myelinated axons in the distal nerve stump in the fibrin-conduit group reached 86% of the control and the weight of gastrocnemius and soleus muscles recovered to 82% and 89% of the controls, respectively. The present results suggest that a tubular fibrin conduit can be used to promote neuronal regeneration following peripheral nerve injury.

Protein and synthetic polymer injection for induction of obstructive hydrocephalus in rats

Background

The objective of this study was to develop a simple and inexpensive animal model of induced obstructive hydrocephalus with minimal tissue inflammation, as an alternative to kaolin injection.

Materials

Two-hundred and two male Sprague-Dawley rats aged 3 weeks received intracisternal injections of kaolin (25% suspension), Matrigel, type 1 collagen from rat tail, fibrin glue (Tisseel), n-butyl-cyanoacrylate (NBCA), or ethylene vinyl alcohol copolymer (Onyx-18 and Onyx-34). Magnetic resonance imaging was used to assess ventricle size. Animals were euthanized at 2, 5, 10 and 14 days post-injection for histological analysis.

Results

Kaolin was associated with 10% mortality and successful induction of hydrocephalus in 97% of survivors (ventricle area proportion 0.168 ± 0.018). Rapidly hardening agents (fibrin glue, NBCA, vinyl polymer) had high mortality rates and low success rates in survivors. Only Matrigel had relatively low mortality (17%) and moderate success rate (20%). An inflammatory response with macrophages and some lymphocytes was associated with kaolin. There was negligible inflammation associated with Matrigel. A severe inflammatory response with giant cell formation was associated with ethylene vinyl alcohol copolymer.

Conclusion

Kaolin predictably produces moderate to severe hydrocephalus with a mild chronic inflammatory reaction and fibrosis of the leptomeninges. Other synthetic polymers and biopolymers tested are unreliable and cause different types of inflammation.

Peripheral nerve regeneration using a three dimensionally cultured schwann cell conduit

The use of artificial nerve conduit containing viable Schwann cells is one of the most promising strategies to repair peripheral nerve injury. To fabricate an effective nerve conduit whose microstructure and internal environment are more favorable in nerve regeneration than those currently existing, a new three-dimensional (3D) Schwann cell culture technique using Matrigel and dorsal root ganglion (DRG) was developed. Nerve conduit of 3D arranged Schwann cells was fabricated using direct seeding of freshly harvested DRG into Matrigel-filled silicone tubes (inner diameter 1.98 mm, 14 mm length) and in vitro rafting culture for 2 weeks. The nerve regeneration efficacy of 3D cultured Schwann cell conduit (3D conduit group, n = 6) was assessed using an Sprague-Dawley rat sciatic nerve defect of 10 mm and compared with that of a silicone conduit filled with Matrigel and Schwann cells prepared with the conventional plain culture method (two-dimensional [2D] conduit group, n = 6). After 12 weeks, sciatic function was evaluated with sciatic function index (SFI) and gait analysis, and histomorphology of nerve conduit and the innervated tissues of sciatic nerve were examined using image analyzer and electromicroscopic methods. The SFI and ankle stance angle in the functional evaluation were -60.1 +/- 13.9, 37.9 degrees +/- 5.4 degrees in the 3D conduit group (n = 5) and -87.0 +/- 12.9, 32.2 degrees +/- 4.8 degrees in the 2D conduit group (n = 4). The myelinated axon was 44.91% +/- 0.13% in the 3D conduit group and 13.05% +/- 1.95% in the 2D conduit group. In the transmission electron microscope study, the 3D conduit group showed more abundant myelinated nerve fibers with well-organized and thickened extracellular collagen than the 2D conduit group, and the gastrocnemius muscle and biceps femoris tendon in the 3D conduit group were less atrophied and showed decreased fibrosis with less fatty infiltration than the 2D conduit group. A new 3D Schwann cell culture technique was established, and nerve conduit fabricated using this technique showed much improved nerve regeneration capacity than the silicone tube filled with Matrigel and Schwann cells prepared from the conventional plain culture method.

Risk reduction of subdural collections following endoscopic third ventriculostomy

OBJECT

To evaluate the efficacy and safety using fibrin glue and absorbable hemostats for packing the endoscopic tract in a pediatric population in the prevention of subdural fluid collections after endoscopic third ventriculostomy.

MATERIALS AND METHODS

Twenty-one endoscopic third ventriculostomies were performed in 20 hydrocephalic children with a mean age of 22 months over a 4-year period using uniformly this technique. Six children, with age ranged 6 days to 22 months (mean 9 months), had severe ventriculomegaly with thin brain mantle less than 10 mm. There was no mortality and no permanent morbidity related to the endoscopic procedure. One child developed an asymptomatic collection, which could be managed conservatively and was most likely attributed to the young age of the child and the assumed poor cerebrospinal fluid absorption ability. Lost compliance of the brain parenchyma may play an additional role, which was not related to the thickness of the brain mantle. No adverse effects regarding the material used for sealing were observed over a mean follow-up of 23 months.

CONCLUSIONS

Subdural fluid collections could be prevented in 20 out of 21 procedures by using this technique regardless of the thickness of the brain mantle, the application of mixture of fibrin glue and hemostatic agents seems to be safe, and we consider this technique effective in reducing the risk of this potential complication.

Electrical stimulation promotes peripheral axon regeneration by enhanced neuronal neurotrophin signaling

Electrical stimulation of cut peripheral nerves at the time of their surgical repair results in an enhancement of axon regeneration. Regeneration of axons through nerve allografts was used to evaluate whether this effect is due to an augmentation of cell autonomous neurotrophin signaling in the axons or signaling from neurotrophins produced in the surrounding environment. In the thy-1-YFP-H mouse, a single 1 h application of electrical stimulation at the time of surgical repair of the cut common fibular nerve results in a significant increase in the proportion of YFP+ dorsal root ganglion neurons, which were immunoreactive for BDNF or trkB, as well as an increase in the length of regenerating axons through allografts from wild type litter mates, both 1 and 2 weeks later. Axon growth through allografts from neurotrophin-4/5 knockout mice or grafts made acellular by repeated cycles of freezing and thawing is normally very poor, but electrical stimulation results in a growth of axons through these grafts, which is similar to that observed through grafts from wild type mice after electrical stimulation. When cut nerves in NT-4/5 knockout mice were electrically stimulated, no enhancement of axon regeneration was found. Electrical stimulation thus produces a potent enhancement of the regeneration of axons in cut peripheral nerves, which is independent of neurotrophin production by cells in their surrounding environment but is dependent on stimulation of trkB and its ligands in the regenerating axons themselves.

Effect of arachnoid plasty using fibrin glue membrane after clipping of ruptured aneurysm on the occurrence of complications and outcome in the elderly patients

BACKGROUND

In elderly patients with aneurysmal subarachnoid hemorrhage (SAH), complications including vasosopasm, subdural effusion, and late hydrocephalus, are liable to occur even after aneurysmal surgery. We examined prospectively the efficacy of arachnoid plasty using fibrin glue membrane during surgery of ruptured aneurysms in the elderly patients for preventing complications. The effects on the modified Rankin scale (mRS) and the Glasgow outcome scale (GOS) 3 months after SAH were noted.

METHODS

Total of 31 patients aged more than 70 years selected from a consecutive series of patients with aneurysmal SAH, were divided into two groups alternately, a group with arachnoid plasty (n = 16) and a control group without arachnoid plasty (n = 15). Statistical analyses were performed to assess relationships among various clinical and neuroradiological variables, especially between arachnoid plasty and occurrence of symptomatic vasospasm, subdural effusion, late hydrocephalus, or outcome such as mRS and GOS 3 months after onset.

FINDINGS

Statistical analyses revealed that arachnoid plasty were associated with late hydrocephalus and subdural effusion negatively, but with better mRS at 3 months after SAH. A tendency to be associated with less frequent symptomatic vasospasm was also noted.

CONCLUSION

Arachnoid plasty using fibrin glue is suggested to be effective in preventing complications associated with SAH and aneurysmal surgery. A better outcome in the elderly patients can be achieved.

Comparative dural closure techniques: a safety study in rats

BACKGROUND

Some neurosurgical procedures have high morbidity and mortality rates due to cerebrospinal fluid (CSF) fistula development, particularly when dural defects are in relatively inaccessible areas or surrounded by friable dura. We used a rat model to test 4 different dural closure techniques to determine which one was significantly superior for achieving a watertight dural closure with minimal harm to brain tissue.

METHODS

The rats were randomly divided into 2 groups. The first group (group A, n = 40) was used to test the strength of the adhesivity for CSF leakage. Histopathologic studies were used to evaluate the granulation tissue between the dura and dural graft. Effects on the brain tissue were studied in the second group (group B, n = 40) where lipid peroxidation was determined. These 2 groups consisted of 5 subgroups: control, methyl metacrylate, n-butyl cyanoacrylate, fibrin glue, and CO(2) laser.

RESULTS

Methyl metacrylate and CO(2) laser techniques were inadequate for stopping dural leakage and had harmful effects on brain tissue. Cerebrospinal fluid leak was observed only in 1 rat in the n-butyl cyanoacrylate subgroup and this result was statistically significant (P = .0005), but lipid peroxidation levels for this material showed that it was not safe for dural closure in case it leaked through the dural defect. The lipid peroxidation levels of the fibrin glue subgroup were not statistically significantly different from the control group (P = .440).

CONCLUSIONS

Fibrin glue was the safest material with a CSF leakage risk that was higher than n-butyl cyanoacrylate (25% vs 12.5%) but acceptable. This study showed no relationship between the CSF leak and histopathologic findings for sealant properties of the tissue adhesives.

Fast-gelling injectable blend of hyaluronan and methylcellulose for intrathecal, localized delivery to the injured spinal cord

Strategies for spinal cord injury repair are limited, in part, by poor drug delivery techniques. A novel drug delivery system (DDS) is being developed in our laboratory that can provide localized release of growth factors from an injectable gel. The gel must be fast-gelling, non-cell adhesive, degradable, and biocompatible as an injectable intrathecal DDS. A gel that meets these design criteria is a blend of hyaluronan and methylcellulose (HAMC). Unlike other injectable gels, HAMC is already at the gelation point prior to injection. It is injectable due to its shear-thinning property, and its gel strength increases with temperature. In vivo rat studies show that HAMC is biocompatible within the intrathecal space for 1 month, and may provide therapeutic benefit, in terms of behavior, as measured by the Basso, Beattie and Bresnahan (BBB) locomotor scale, and inflammation. These data suggest that HAMC is a promising gel for localized delivery of therapeutic agents to the injured spinal cord.

A novel coating biomaterial for intracranial aneurysms: Effects and safety in extra- and intracranial carotid artery

Methyl-2-cyanoacrylate, a widely used material for coating cerebral aneurysm, was recently withdrawn. The aim of the present study was to develop an alternative coating material for cerebral aneurysm, which is safe, effective and stable within the brain. In the first experiment, an aneurysm model of the common carotid artery was produced in a rabbit by the local application of elastase. The aneurysm produced was covered by no material (Group A), a cellulose cotton sheet and conventional methyl-2-cyanoacrylate (Group B), a newly produced polyglycolic acid felt and fibrin glue (Group C), or a cellulose cotton sheet and fibrin glue (Group D). Histological examination showed that the materials resulted in the formation of tight connective tissue around the artery, and that the material was completely replaced by the connective tissue after 12 weeks. This change was found exclusively in Group C, but not in Group A or the other materials, although a temporary thickening of the intima was also observed at the site of the elastase application in Group C. In Group D, a long-term, marked thickening of the intima was observed. In the second experiment, using an intracranial internal carotid artery from a beagle, the applied polyglycolic acid felt and fibrin glue to the intracranial artery induced the formation of connective tissue around the artery that was completely absorbed 16 weeks after surgery. There were no signs of intimal thickening or of adverse reactions in nervous tissue. The present results suggest that polyglycolic acid felt and fibrin glue is a possible candidate for a safe, effective biomaterial to wrap or coat cerebral aneurysm.

Effects of Tisseel Fibrin Glue on the Central Nervous System of Nonhuman Primates

For many years, neurosurgeons and otolaryngologic surgeons have used the fibrin glue product Tisseel to repair skull-base spinal fluid leaks and to help secure repairs following anterior cranial-base surgery. Despite the widespread use, the potential focal cerebral toxicity of this fibrin glue has never been investigated. We studied the safety of Tisseel applied directly to neural tissue (brain parenchyma, cervical cord, and C3-C6 spinal roots) of 6 monkeys (Macaca nemestrina) to determine if any underlying biochemical injury would occur. Another 3 animals that served as controls received saline rather than Tisseel. We found that median nerve electroencephalographic tracings and somatosensory evoked potentials in the experimental and control animals were identical. Likewise, cerebrospinal fluid indicators of neuronal or brain injury, inflammatory responses, and infection were negative in both groups. Finally, there were no significant differences between the two groups with respect to edema volumes and apparent diffusion coefficient values. We conclude that Tisseel does not induce an apparent inflammatory response or abnormal neurophysiologic or histologic response within 5 days of its application when it is applied directly to the brain parenchyma or onto the cervical spinal cord.