Dural sealants for the management of cerebrospinal fluid leakage after intradural surgery: current status and future perspectives

Preventing Post-incisional Dural Shrink in Craniotomy: Introducing the "Roll-up Technique"

Dural dryness makes suturing difficult during dural closure after craniotomy. In this case, dural plasty is often performed using a membrane taken from the surrounding tissue (e.g., fascia or periosteum) or an artificial replacement membrane. Herein, we introduce our novel "roll-up technique" to reduce the utilization of substitute membranes and explore its effectiveness in dural closure. We retrospectively examined the medical records of 50 patients who underwent craniotomy for the first time for supratentorial intracranial lesions between 2015 and 2022. Furthermore, we divided them into two groups: (1) the conventional technique group, which consisted of patients in whom the dura mater was flipped after incision and protected with a moistened gauze (n = 23), and (2) the roll-up technique group, which consisted of patients in whom the dura mater was incised in a U shape, rolled up, and protected with a moist gauze (n = 27). After surgery, we compared the success rates of primary closure, operating time, craniotomy area, and percentage of complications (e.g., cerebrospinal fluid [CSF] leakage or infection) between the groups. Dural closure without dural substitutes using the roll-up technique had a higher success rate than that using the conventional technique (26/27 [96.3%] cases vs. 14/23 [60.9%] cases; P = 0.003). Postoperative CSF leakage or infection did not occur, and no statistically significant difference was observed in the operating time between the groups (P = 0.247). The roll-up technique for dural closure may effectively prevent post-incisional dural shrink after craniotomy.

Biomimetic and Nonbiomimetic Approaches in Dura Substitutes: The Influence of Mechanical Properties

The dura mater, the furthest and strongest layer of the meninges, is crucial for protecting the brain and spinal cord. Its biomechanical behavior is vital, as any alterations can compromise biological functions. In recent decades, interest in the dura mater has increased due to the need for hermetic closure of dural defects prompting the development of several substitutes. Collagen-based dural substitutes are common commercial options, but they lack the complex biological and structural elements of the native dura mater, impacting regeneration and potentially causing complications like wound/postoperative infection and cerebrospinal fluid (CSF) leakage. To face this issue, recent tissue engineering approaches focus on creating biomimetic dura mater substitutes. The objective of this review is to discuss whether mimicking the mechanical properties of native tissue or ensuring high biocompatibility and bioactivity is more critical in developing effective dural substitutes, or if both aspects should be systematically linked. After a brief description of the properties and architecture of the native cranial dura, we describe the advantages and limitations of biomimetic dura mater substitutes to better understand their relevance. In particular, we consider biomechanical properties' impact on dura repair's effectiveness. Finally, the obstacles and perspectives for developing the ideal dural substitute are explored.

Sprayable Hydrogel Sealant for Gastrointestinal Wound Shielding

Naturally occurring internal bleeding, such as in stomach ulcers, and complications following interventions, such as polyp resection post-colonoscopy, may result in delayed (5-7 days) post-operative adverse events-such as bleeding, intestinal wall perforation, and leakage. Current solutions for controlling intra- and post-procedural complications are limited in effectiveness. Hemostatic powders only provide a temporary solution due to their short-term adhesion to GI mucosal tissues (less than 48 h). In this study, a sprayable adhesive hydrogel for facile application and sustained adhesion to GI lesions is developed using clinically available endoscopes. Upon spraying, the biomaterial (based on polyethyleneimine-modified Pluronic micelles precursor and oxidized dextran) instantly gels upon contact with the tissue, forming an adhesive shield. In vitro and in vivo studies in guinea pigs, rabbits, and pig models confirm the safety and efficacy of this biomaterial in colonic and acidic stomach lesions. The authors' findings highlight that this family of hydrogels ensures prolonged tissue protection (3-7 days), facilitates wound healing, and minimizes the risk of delayed complications. Overall, this technology offers a readily adoptable approach for gastrointestinal wound management.

Dural Closure Training With Prototyped Model

INTRODUCTION

The hermetic closure of the dura mater is a critical step in neurosurgical training, often undervalued but crucial to preventing serious complications such as cerebrospinal fluid (CSF) leaks leading to meningitis and death. Inadequate closure, often due to insufficient training, can result in challenging complications, including prolonged hospitalization and reoperation.

OBJECTIVE

To address the deficiencies in dural closure training, this study aims to describe a 3D prototype for simulating post-craniotomy dura mater suturing. The objective is to reduce the incidence of CSF leaks and improve the training of neurosurgery residents.

DESIGN

The study involves the creation of a 3D prototype based on magnetic resonance imaging and computed tomography scans. The additive manufacturing of structures is performed using ABS filament, and a silicone rubber membrane is used to simulate the meningeal dura mater. Neurosurgery residents undergo training using this model, and the effectiveness is evaluated.

SETTING

The study is conducted at the Institute of Neurology of Curitiba (Hospital INC), focusing on neurosurgery residents from the first to fifth year of residency.

PARTICIPANTS

Seven residents participate in the study, with varying levels of experience in dural closure procedures. The training involves a simulated surgical environment using the 3D prototype.

RESULTS

After training, residents show improvements in confidence and theoretical knowledge related to dural closure. Binary questions indicate a strong desire for more practical training on dural closure, with 85.7% believing in the essential role of 3D molds in their neurosurgery training.

CONCLUSION

The study highlights the importance of adequate training for dural closure to prevent serious complications in neurosurgery. The use of 3D simulation models, despite some limitations, proves to be an effective educational strategy. The emerging technology of bioprinting holds promise for further enhancing simulation materials, bringing medical education closer to realistic tissue replication.

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

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

Trans-Defect Underlay Watertight Duraplasty for Traumatic Anterior Skull Base Dural Defect: Technical Report

BACKGROUND

Watertight duraplasty is essential for surgical management of traumatic anterior skull base (ASB) dural defect but challenging in the deep and narrow operative corridor. Here, the authors report a trans-defect underlay watertight duraplasty (TDUWD) technique for traumatic ASB dural defect.

METHODS

TDUWD was performed by inserting a free pericranium graft under the dural defect. The diameter of the pericranium graft was larger than the dural defect. The pericranium graft was sutured to the dural defect watertightly in an "inside-to-outside" direction, with the needle not penetrating the inner layer of pericranium graft. The pedicled pericranium flap was used as a second layer of reconstruction. The characteristics, complications, and outcomes of patients who received TDUWD are reported.

RESULTS

A total of 29 patients received TDUWD. Immediate postoperative cessation of cerebrospinal fluid (CSF) leak occurred in 28 patients. One patient recovered after lumber drainage. No patient needed a second operation or reported delayed recurrence of CSF leak. No complication related to the surgical technique was observed.

CONCLUSIONS

Use of TDUWD for traumatic ASB dural defect results in an immediate, 1-stage, and definitive correction of CSF leak and seems to be simple, safe, and reliable for large and deeply located dural defects.

PEG hydrogel sealant versus fibrin glue in posterior fossa surgery: an economic comparison across five European countries

Aim: Posterior cranial fossa (PCF) surgery is associated with complications, including cerebrospinal fluid (CSF) leakage. Dural sealants such as polyethylene glycol (PEG)-based hydrogels and fibrin glue can prevent CSF leaks, with evidence suggesting PEG hydrogels may outperform fibrin glue. However, the budget impact of using PEG hydrogels in PCF surgeries in Europe is unclear. Materials & methods: A decision tree was developed based on a previous US model, to assess the budget impact of switching from fibrin glue to PEG hydrogel in PCF surgery across five European countries. Input costs were derived from published sources for the financial year 2022/2023. Health outcomes, including CSF leaks, were considered. Results: The model predicted that using PEG hydrogel instead of fibrin glue in PCF surgery can lead to cost savings in five European countries. Cost savings per patient ranged from EUR 419 to EUR 1279, depending on the country. Sensitivity analysis showed that the incidence of CSF leaks and pseudomeningoceles had a substantial impact on the model's results. Conclusion: PEG hydrogels may be a cost-effective alternative to fibrin glue in PCF surgery. The model predicted that cost savings would be mainly driven by a reduction in the incidence of postoperative CSF leaks, resulting in reduced reliance on lumbar drains, reparative surgery and shortened hospital stays.

Enhanced Dural Repair Using Biodegradable Sealants Based on Photocurable Hyaluronic Acid

Cerebrospinal fluid (CSF) leakage is a common complication of intradural surgery or incidental durotomy in neurosurgery. Dural suturing is a common method for durotomy repair, but this technique requires a long operation time and includes the risk of CSF leakage by incomplete sealing. Glue-type sealants are effective for watertight dural closure. However, unresolved shortcomings include insufficient sealing performance, poor biocompatibility, and excessive swelling. Here, a dural sealant using light-activated hyaluronic acid (HA) with multi-networks (HA photosealant) that provides fast sealing performance and high biocompatibility is reported. The HA photosealants form a watertight hydrogel barrier with multilength networks under low-energy visible light exposure (405 nm, <1 J cm-2) for 5 s and allow firm tissue adhesion on the wet dural surface. In a rabbit model of craniectomy and durotomy, HA photosealants exhibit the faster sealing performance of dural tears and enhance dural repair with accelerated bone formation compared to commercial surgical glues, with no degenerative changes, such as inflammation or necrosis, in histopathological evaluation. This biocompatible HA photosealant can be applied in a variety of clinical settings that require fast wound closure as a promising potential.

A tough bioadhesive hydrogel supports sutureless sealing of the dural membrane in porcine and ex vivo human tissue

Complete sequestration of central nervous system tissue and cerebrospinal fluid by the dural membrane is fundamental to maintaining homeostasis and proper organ function, making reconstruction of this layer an essential step during neurosurgery. Primary closure of the dura by suture repair is the current standard, despite facing technical, microenvironmental, and anatomic challenges. Here, we apply a mechanically tough hydrogel paired with a bioadhesive for intraoperative sealing of the dural membrane in rodent, porcine, and human central nervous system tissue. Tensile testing demonstrated that this dural tough adhesive (DTA) exhibited greater toughness with higher maximum stress and stretch compared with commercial sealants in aqueous environments. To evaluate the performance of DTA in the range of intracranial pressure typical of healthy and disease states, ex vivo burst pressure testing was conducted until failure after DTA or commercial sealant application on ex vivo porcine dura with a punch biopsy injury. In contrast to commercial sealants, DTA remained adhered to the porcine dura through increasing pressure up to 300 millimeters of mercury and achieved a greater maximum burst pressure. Feasibility of DTA to repair cerebrospinal fluid leak in a simulated surgical context was evaluated in postmortem human dural tissue. DTA supported effective sutureless repair of the porcine thecal sac in vivo. Biocompatibility and adhesion of DTA was maintained for up to 4 weeks in rodents after implantation. The findings suggest the potential of DTA to augment or perhaps even supplant suture repair and warrant further exploration.

Clinical management of dural defects: A review

Dural defects are common in spinal and cranial neurosurgery. A series of complications, such as cerebrospinal fluid leakage, occur after rupture of the dura. Therefore, treatment strategies are necessary to reduce or avoid complications. This review comprehensively summarizes the common causes, risk factors, clinical complications, and repair methods of dural defects. The latest research progress on dural repair methods and materials is summarized, including direct sutures, grafts, biomaterials, non-biomaterial materials, and composites formed by different materials. The characteristics and efficacy of these dural substitutes are reviewed, and these materials and methods are systematically evaluated. Finally, the best methods for dural repair and the challenges and future prospects of new dural repair materials are discussed.

Late presentation of dural tears: Two case reports and review of literature

BACKGROUND

The late presentation of dural tears (LPDT) has a low incidence rate and hidden symptoms and is easily ignored in clinical practice. If the disease is not treated in time, a series of complications may occur, including low intracranial pressure headache, infection, pseudodural cyst formation, and sinus formation. Here, we describe two cases of LPDT.

CASE SUMMARY

Two patients had sudden fever 1 wk after lumbar surgery. Physical examination showed obvious tenderness in the operation area. The patients were confirmed as having LPDT by lumbar magnetic resonance imaging and surgical exploration. One case was caused by continuous negative pressure suction and malnutrition, and the other was caused by decreased dural ductility and low postoperative nutritional status. The first symptom of both patients was fever, with occasional headache. Both patients underwent secondary surgery to treat the LPDT. Dural defects were observed and dural sealants were used to seal the dural defects, then drainage tubes were retained for drainage. After the operation, the patients were treated with antibiotics and the patients’ surgical incisions healed well, without fever or incision tenderness. Both recovered and were discharged 1 wk after the operation.

CONCLUSION

LPDT is a rare complication of spinal surgery or neurosurgery that has hidden symptoms and can easily be overlooked. Since it may cause a series of complications, LPDT needs to be actively addressed in clinical practice.

Lumbar Cistern Drainage and Gentamicin Intrathecal Injection in the Treatment of Carbapenem-Resistant Klebsiella Pneumoniae Intracranial Infection After Intracerebral Hemorrhage craniotomy: A Case Report

Background

Intracranial infection is a common complication caused by craniotomy. In particular, patients in Intensive Care Units (ICU) are prone to intracranial infection with multiple drug-resistant bacteria. Due to the lack of sensitive antibiotics for the treatment of multiple drug-resistant bacteria, there are few literatures focusing on the treatment of intracranial infection, and patients often fail to receive unified and standardized treatment. Consequently, patients with Carbapenem-resistant bacteria intracranial infection report poor prognosis and high mortality. It is very important to discuss how to treat patients with intracranial infection caused by multidrug resistant bacteria.

Case Presentation

We reported a case of intracranial infection of Carbapenem-resistant Klebsiella pneumoniae(CRKp) due to high flap tension, poor wound healing and CSF leakage caused by subcutaneous fluid accumulation after intracerebral hemorrhage craniotomy. Since the patient was exposed to intracranial infection resulted from subcutaneous fluid accumulation, we adopted the method of continuous drainage with subcutaneous tube. When subcutaneous effusion disappeared, the subcutaneous drainage tube was pull out, while patients exhibited high fever again, the waist big pool drainage catheter and continuous drainage were carried out. According to the result of Subcutaneous effusion and CSF culture indicated multiple drug resistant Klebsiella pneumoniae intracranial infection and drug susceptibility, The treatment of gentamicin intrathecal injection, intravenous use amikacin and oral Paediatric Compound Sulfamethoxazole Tablets was adopted, the condition of intracranial infection was eventually controlled, with the consciousness restored. This patient was characterized by intracranial infection with Carbapenem-resistant Klebsiella pneumoniae(CRKp).

Conclusions

Subcutaneous effusion is a high-risk factor for poor wound healing and interventions are required to be conducted to promote healing as early as possible to contribute to decreasing the menace of CSF leakage. In this case, Continuous drainage and intrathecal injection of sensitive antibiotics serve as critical process to determine the best strategy for clinical treatment of intracranial infection.

Association between synthetic sealants and increased complication rates in posterior fossa decompression with duraplasty for Chiari malformations regardless of graft type

OBJECTIVE

Dural sealants are commonly used in posterior fossa decompression with duraplasty (PFDD) for Chiari malformation type I (CMI). Prior evidence suggests that combining certain sealants with some graft material is associated with an increased rate of complications. In 2018, the authors noted an increased rate of symptomatic pseudomeningocele and aseptic meningitis after PFDD in CMI patients. The authors utilized retrospective and prospective analyses to test the hypothesis that complication rates increase with the use or combination of certain sealants and grafts.

METHODS

The analysis was split into 2 periods. The authors retrospectively reviewed patients who underwent PFDD for CMI at their center between August 12, 2011, and December 31, 2018. The authors then eliminated use of DuraSeal on the basis of the retrospective analysis and prospectively examined complication rates from January 1, 2019, to August 4, 2021. The authors defined a complication as symptomatic pseudomeningocele, bacterial or aseptic meningitis, cerebrospinal fluid leak, subdural hygroma, hydrocephalus, surgical site infection, or wound dehiscence.

RESULTS

From 2011 to 2018, complications occurred in 24.5% of 110 patients. Sealant choice was correlated with complication rates: no sealant (0%), Tisseel (6%), and DuraSeal (15.3%) (p < 0.001). No difference in complication rate was noted on the basis of choice of graft material (p = 0.844). After eliminating DuraSeal, the authors followed 40 patients who underwent PFDD after 2018. The complication rate decreased to 12.5%. All complications after 2018 were associated with Tisseel.

CONCLUSIONS

At the authors' single center, use of sealants in PFDD surgery for CMI, especially DuraSeal, was correlated with a higher complication rate. Eliminating DuraSeal led to a significant decrease in the rate of symptomatic pseudomeningocele and aseptic meningitis.

Risk Factors for Postoperative Cerebrospinal Fluid Leakage After Intradural Spine Surgery

OBJECTIVE

Well-defined risk factors for cerebrospinal fluid leakage (CSFL) after intradural spine surgery are scarce in the literature. The aim of the present study was to identify patient- and surgery-related risk factors and the incidence of CSFL.

METHODS

For the present retrospective cohort study, we identified consecutive patients who had undergone intradural spine surgery between 2009 and 2021 at our department. The primary endpoint was the incidence of clinically or radiologically proven CSFL. The effects of the clinical and surgical factors on the occurrence of CSFL were analyzed.

RESULTS

A total of 375 patients (60.3% women; mean age, 54 ± 16.5 years) were included. Of the 375 patients, 30 (8%) had experienced postoperative CSFL and, thus, a significantly greater risk of wound healing disorders (odds ratio [OR], 24.9; 95% confidence interval [CI], 9.3-66.7) and surgical site infections (OR, 8.4; 95% CI, 2.6-27.7; P < 0.01 for each). No patient-related factors were associated with the development of CSFL. Previous surgery at the index level correlated significantly with the occurrence of postoperative CSFL (OR, 2.76; 95% CI, 1.1-6.8; P = 0.03) on multivariate analysis. Furthermore, patients with intradural tumors tended to have a greater risk of CSFL (OR, 2.3; 95% CI, 0.9-5.8; P = 0.07). Surgery-related factors did not influence the occurrence of CSFL. Surgery on the thoracic spine had resulted in a significantly lower postoperative CSFL rate compared with surgery on the cervical or lumbar spine (OR, -2.5; 95% CI, 1.3-4.9; P = 0.02).

CONCLUSIONS

Our study found no modifiable risk factors for preventing CSFL after intradural spine surgery. Patients with previous surgery at the index level had a greater risk of CSFL. The occurrence of CSFL resulted in significantly more wound healing disorders and surgical site infections, necessitating further therapy.

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

BACKGROUND

Cerebrospinal fluid (CSF) leak remains a significant source of morbidity after neurosurgical procedures. The objective is to evaluate the effectiveness and safety of a polyethylene glycol-coated collagen patch (PCC) in different neurosurgical procedures.

METHODS

A retrospective, single-center cohort study in patients who underwent a cranial neurosurgical procedure. After collecting multiple data variables, patients were divided into two groups depending on the use of PCC as sealant on dural closure following procedures.

RESULTS

Data from 230 patients were collected (PCC, 128; control group, 102). Incidence of CSF leakage was significantly lower in the PCC group (p < .001). Complications that were significantly lower in PCC than the control group included surgical infection (p = .022), and hydrocephalus (p = .017), as well as reduced rates of reintervention (p < .001) and shorter hospital stays (p = .028). Factors associated with a higher incidence of CSF leakage included posterior fossa procedures, reinterventions, and the need for CSF drainage placement. PCC reduced the risk of suffering CSF leakage by more than 75% (p = .002) once adjusted for age, surgical approach, type of cranial opening, reintervention, CSF drainage, dural substitute, and dural defect coverage.

CONCLUSIONS

Our findings confirm PCC as an effective means of preventing CSF leakage following cranial neurosurgery with fewer associated complications.

Electrospinning of cyanoacrylate tissue adhesives for human dural repair in endonasal surgery

Cerebral spinal fluid (CSF) leakage is a major postoperative complication requiring surgical intervention, resulting in prolonged healing and higher costs. Biocompatible polymers, such as cyanoacrylates, are currently used as tissue adhesives for closing surgical defects and incisions. Coupling these polymers with nanofiber technology shows promising results for generating nanofibers used in wound care, tissue engineering, and drug delivery. Fiber membranes formed by electrospinning of n-octyl-2-cyanoacrylate (NOCA) are investigated for in situ dural closures after neurosurgery to improve the quality of the closure and prevent post-surgical CSF leaks. Electrospun NOCA fiber membranes showed significantly higher sealing capabilities of defects in human dura, with an average burst pressure of 149 mmHg, compared with that of an FDA-approved common dural sealant that had an average burst pressure of 37 mmHg. In this study, microfabrication of NOCA fibers demonstrates a promising technique for dural repairs.

Liquid Copolymers as Biodegradable Surgical Sealant

Surgical sealants are widely used to prevent seepage of fluids and liquids, promote hemostasis, and close incisions. Despite the remarkable progress the field of biomaterials has undergone, the clinical uses of surgical sealants are limited because of their short persistence time in vivo, toxicity, and high production costs. Here, the development of two complementary neat (solvent-free) prepolymers, PEG₄ -PLGA-NHS and PEG₄ -NH₂ , that harden upon mixing to yield an elastic biodegradable sealant is presented. The mechanical and rheological properties and cross-linking rate can be controlled by varying the ratio between the two prepolymers. The tested sealants show a longer persistence time compared with fibrin glue, minimal cytotoxicity in vitro, and excellent biocompatibility in vivo. The neat, multiarmed approach demonstrated here improves the mechanical and biocompatibility properties and provides a promising tissue sealant solution for wound closure in future surgical procedures.

High efficacy of tetra-PEG hydrogel sealants for sutureless dural closure

Advances in meticulous dural closure technique remain a great challenge for watertight dural closure in the aged society, because the cerebrospinal fluid (CSF) leakage after spinal surgery is often accompanied with the disgusting wound infection, meningitis and pseudomeningocele. Here, a tetra-poly (ethylene glycol) (PEG)-based hydrogel sealant is developed with collective advantages of facile operation, high safety, quick set time, easy injectability, favorable mechanical strength and powerful tissue adhesion for effective sutureless dural closure during the surgery procedure. Impressively, this tetra-PEG sealant can instantaneously adhere to the irregular tissue surfaces even in a liquid environment, and effectively prevent or block off the intraoperative CSF leakage for sutureless dural closure and dura regeneration. Together, this sutureless tetra-PEG adhesive can be utilized as a very promising alternative for high-efficient watertight dural closure of the clinical patients who incidentally or deliberately undergo the durotomy during the spinal surgery.

A biomimetic triple-layered biocomposite with effective multifunction for dura repair

Dura mater defect and subsequent cerebrospinal fluid (CSF) leakage usually appear in trauma or neurosurgical procedures and are followed by a series of serious complications and even death. The use of a qualified dura mater substitute with multifunction of leakage blockade, adhesion prevention, and dura reconstruction is one of the promising treatment methods. However, even though some products have been used in the clinic, none of the substitutes achieved the required multifunction. In this study, we aimed to design and fabricate a dura repair composite with the ideal multifunction. By biomimicking the structure and component of natural dura, we applied poly(L-lactic acid) (PLLA), chitosan (CS), gelatin, and acellular small intestinal submucosa (SIS) powders to successfully prepare a triple-layered composite. Then, a series of specific devices and techniques were developed to investigate the performance. The results revealed that satisfactory structural stability could be realized under good synergistic interactions among the components. In addition, all the findings suggested that the bionic triple-layered composite showed satisfactory multifunction of leakage blockade, adhesion prevention, antibacterial property, and dura reconstruction potential, and thus, it might be a promising candidate for dura repair. STATEMENT OF SIGNIFICANCE: Developing qualified dura mater substitutes with multifunction of leakage blockade, adhesion prevention, and dura reconstruction is crucial for treating dura mater defect and subsequent cerebrospinal fluid (CSF) leakage that appear in trauma or neurosurgical procedures. In this study, we designed and fabricated a triple-layered dura repair biocomposite with satisfactory structural stability and desired multifunction based on biomimicking of the structure and component of natural dura. Moreover, a series of specific devices and techniques were developed to investigate the relevant performance. Overall, the developed hydrogel electrospinning system exhibited excellent advantages in achieving multifunction and could be applied widely in the future to achieve multifunctional tissue repair materials.

Ex vivo evaluation of a multilayered sealant patch for watertight dural closure: cranial and spinal models

Cerebrospinal fluid leakage is a frequent complication after cranial and spinal surgery. To prevent this complication and seal the dura watertight, we developed Liqoseal, a dural sealant patch comprising a watertight polyesterurethane layer and an adhesive layer consisting of poly(DL-lactide-co-ε-caprolactone) copolymer and multiarmed N-hydroxylsuccinimide functionalized polyethylene glycol. We compared acute burst pressure and resistance to physiological conditions for 72 h of Liqoseal, Adherus, Duraseal, Tachosil, and Tisseel using computer-assisted models and fresh porcine dura. The mean acute burst pressure of Liqoseal in the cranial model (145 ± 39 mmHg) was higher than that of Adherus (87 ± 47 mmHg), Duraseal (51 ± 42 mmHg) and Tachosil (71 ± 16 mmHg). Under physiological conditions, cranial model resistance test results showed that 2 of 3 Liqoseal sealants maintained dural attachment during 72 hours as opposed to 3 of 3 for Adherus and Duraseal and 0 of 3 for Tachosil. The mean burst pressure of Liqoseal in the spinal model (233 ± 81 mmHg) was higher than that of Tachosil (123 ± 63 mmHg) and Tisseel (23 ± 16 mmHg). Under physiological conditions, spinal model resistance test results showed that 2 of 3 Liqoseal sealants maintained dural attachment for 72 hours as opposed to 3 of 3 for Adherus and 0 of 3 for Duraseal and Tachosil. This novel study showed that Liqoseal is capable of achieving a strong watertight seal over a dural defect in ex vivo models.

Effect of subdural muscle packing in repairing dura mater after retrosigmoid craniotomy

Objective

This study was performed to evaluate a new type of autologous muscle tamponade to repair dura mater that has undergone dural defects to prevent cerebrospinal fluid leakage or subcutaneous fluid accumulation.

Methods

Three hundred thirty-two patients who underwent retrosigmoid craniotomy were selected and divided into two groups: bone window craniotomy and bone flap craniotomy. Each group was further divided into two groups: artificial dura repair and autologous muscle repair. We then analysed the incidence of postoperative cerebrospinal fluid leakage or subcutaneous fluid accumulation and compared the effects of the two repair methods.

Results

For all patients, autologous muscle repair of the dura mater had a lower incidence of cerebrospinal fluid leakage than artificial dura mater repair, especially in patients with craniotomy.

Conclusions

Subdural craniotomy of the bone window is more effective than conventional methods in preventing cerebrospinal fluid leakage.

Ten-Year Experience of Dural Reconstruction Using a Collagen Matrix Inlay Graft in Posterior Fossa Surgery: A Propensity Score-Matched Study

BACKGROUND

Considering that primary watertight dural closure is not always possible following posterior fossa surgery, several methods of dural reconstruction were proposed to reduce the risk of cerebrospinal fluid (CSF) leakage. This study aimed to evaluate the efficacy of collagen matrix inlay graft compared with other techniques in a propensity score-matched cohort.

METHODS

Between 2000 and 2019, 176 consecutive patients who underwent posterior fossa surgery were enrolled. Of these, 103 patients underwent dural reconstruction with collagen matrix inlay graft (inlay group). After propensity score matching, 67 pairs were derived. The primary outcome was the development of CSF leakage. Pseudomeningocele and surgical site infection were also investigated.

RESULTS

Median follow-up period was 53.9 months. None of the patients in the inlay group had CSF leakage; however, leakage was evident in 5 patients (6.8%) who underwent dural reconstruction without a collagen matrix inlay graft (no-inlay group; P = 0.011). Pseudomeningocele was noted in 1 (1.4%) patient in the no-inlay group, while surgical site infection was noted in 3 (3.0%) patients in the inlay group and 4 (5.5%) patients in the no-inlay group. None of the surgical site infections were related to the use of the inlay graft. After propensity score matching, CSF leakage was still prevalent in the no-inlay group (P = 0.042).

CONCLUSIONS

Dural reconstruction using a collagen matrix inlay graft efficiently reduces CSF leakage after posterior fossa surgery and does not increase the risk of postoperative infection and inflammation. It seems to be a feasible option for dural reconstruction.