Arachnoid Membrane Suturing for Prevention of Subdural Fluid Collection in Extracranial-intracranial Bypass Surgery

Arachnoid Welding-A Simple and Economical Method of Arachnoid Closure to Prevent Cerebrospinal Fluid Leak

BACKGROUND

Collection of cerebrospinal fluid (CSF) in the subdural compartment is a major cause of postoperative morbidity, especially for posterior fossa surgeries. Arachnoid closure techniques, including suturing of the arachnoid and use of synthetic sealants, have been described in the literature. However, they are not always feasible or effective and have not been universally adopted.

METHODS

We describe the technique of arachnoid welding for a case of brainstem cavernoma. This is a simple, cost-effective, and easily reproducible technique using readily available bipolar cautery kept at a low-current setting. At the end of surgery, the arachnoid leaflets are closely approximated, and bipolar cautery is used to seal the edges together. An illustrative video shows the technical nuances of this procedure. This technique can also be applied for arachnoid closure at other cranial and spinal sites.

RESULTS

Arachnoid closure can act as an effective natural barrier to keep CSF in its physiological subarachnoid compartment. It provides an additional barrier to prevent CSF leak. It also prevents morbidity associated with adhesions and arachnoiditis. Proper closure of arachnoid makes durotomy during repeat surgery much easier and avoids injury to the underlying pia. A brief review of related literature shows the benefits of closing the arachnoid before dural closure and the different techniques that have been described so far.

CONCLUSIONS

The arachnoid welding technique has a wide application, is easy to learn, and can be used especially for posterior fossa surgeries in which rates of CSF leak are the highest.

The comparison of the watertight and non-watertight dural closure in supratentorial craniotomy: A single-institute 10-year experience with 698 patients

Watertight dural closure (WTDC) is considered crucial by many neurosurgeons in cranial base surgery, infratentorial craniotomy, and spinal intradural procedure. Whether WTDC also reduce complications remains controversial in supratentorial craniotomy. The objective of this study is to investigate the relationship between WTDC and CSF-related complications in supratentorial craniotomy for the resection of space-occupying lesions. A retrospective analysis of patients who suffered from intracranial space-occupying lesions at Beijing Ditan Hospital between January 2011 and December 2021 was conducted. A total of 698 cases were reviewed with attention to the operative approach, subgaleal fluid collection, wound healing impairment, postoperative infection, and post-craniotomy headaches. The study included a total of 423 patients with WTDC and 275 patients without WTDC. Patients without WTDC had a significantly higher rate of infection (10.9% vs 4.5% with WTDC, P = .001). The rate of subgaleal fluid collection was 9.7% in the WTDC group and 11.3% in the non-WTDC group, but this difference was not statistically significant (P = .502). They suffered from a greater incidence of post-craniotomy headaches in the WTDC group (13.5% vs 9.5% in the non-WTDC group), but without statistical significance (P = .109). We also found no difference in wound healing impairment (P = .719). There is less postoperative infection associated with WTDC during intracranial space-occupying lesion removal than without WTDC in supratentorial craniotomy.

Suturing of the Arachnoid Membrane for Reconstruction of the Cisterna Magna: Technical Considerations

BACKGROUND

Postoperative cerebrospinal fluid (CSF) fistula following cranial or spinal surgery is associated with increased morbidity and mortality. To prevent CSF fistulas, various techniques have been described. Here, we describe the arachnoid membrane continuous-running suture technique in cisterna magna reconstruction for preventing postoperative CSF leakage.

METHODS

After craniotomy and dural opening, the incision of the arachnoid of the cisterna magna was performed using a diamond blade. To prevent the arachnoid from drying out and shrinking during surgery, it was periodically irrigated with warm saline solution. Posterior fossa surgery was performed. When closing the membranes, the arachnoid membrane was closed with the running-suture technique. After the first surgical knot was made in the cranial end of the arachnoid opening, continuous suturing with a 2-mm distance between the stitches was performed without stretching them. After every 3 stitches, the free end of the thread was pulled gently along the suturing axis, and the edges of the arachnoid were closed. After the arachnoid edges were approximated, the surgical knot was tied. Watertight closure was checked by performing the Valsalva maneuver at the end of the surgery.

RESULTS

No CSF leakages were observed after surgery.

CONCLUSIONS

Arachnoid membrane suturing seems to be safe and effective in preventing postoperative CSF leakage and CSF-related complications. Using continuous running suturing alone, without any sealant, might be effective in cases with untraumatized arachnoid membrane.

Cisterna magna arachnoid membrane suturing decreases incidence of pseudomeningocele formation and incisional CSF leakage

OBJECTIVE

A pseudomeningocele and an incisional cerebrospinal fluid leak are considered frequent complications following neurosurgical operations. The rate of these complications especially increases following neurosurgical procedures on the posterior cranial fossae. According to some publications, the rate of pseudomeningoceles has been reported as high as 40%, whereas that of incisional cerebrospinal fluid leaks is up to 17%. For the purposes of reducing the risk of these complications after a midline suboccipital craniotomy, we propose suturing the arachnoid membrane of the cisterna magna. In this paper, we present a retrospective analysis of arachnoid membrane suturing.

METHODS

Seventy patients underwent midline suboccipital craniotomy by the first author between 2012 and 2016 at Burdenko Neurosurgery Institute. In this group was included a consecutive group of patients with posterior fossae tumors where the approach was performed through the cisterna magna arachnoid membrane following midline suboccipital craniotomy and dural opening. The patients were divided into two groups. Group 1 included 38 patients to whom cisterna magna arachnoid membrane suturing was performed with monofilament nonabsorbable suture 7.0., and additionally, the suture was sealed with fibrin adhesive sealant TachoComb®. Group 2 included 32 patients without arachnoid membrane suturing. There was no other significant difference in terms of clinical signs and surgical procedures between these groups. In the postoperative period, the frequency of developing a pseudomeningocele and an incisional cerebrospinal fluid leak was assessed in these two groups. The results were evaluated on the basis of clinical, CT, and MRI data performed in the postoperative period.

RESULTS

In the patients who underwent arachnoid membrane suturing (group I), pseudomeningocele formation was observed in one (2.6%) and CSF leak in one (2.6%) of the 38 patients. In group II, in which patients had no arachnoid membrane suturing, we observed pseudomeningocele formation in 11 (34.4%) patients and a CSF leak in 7 (25.0%) out of 28 patients with known follow-up. Statistical analysis of the data indicates a significantly higher risk of postoperative pseudomeningocele formation and/or an incisional cerebrospinal fluid leak in a group of patients who did not undergo arachnoid membrane suturing (p < 0.05).

CONCLUSIONS

Suturing of the arachnoid membrane of the cisterna magna and its further sealing with fibrin adhesive sealant TachoComb® create an additional barrier for preventing cerebrospinal fluid collection in the extradural space. This technique significantly reduces the risk of postoperative pseudomeningocele formation and/or an incisional cerebrospinal fluid leak in patients with midline suboccipital craniotomy.

Safety of Extracranial-Intracranial Arterial Bypass in the Treatment of Moyamoya Disease

OBJECTIVE

The purpose of this study is to uncover the controversial problems and review the safety of extracranial-intracranial arterial bypass (EC-IC arterial bypass) in the treatment of moyamoya disease.

METHODS

Published randomized controlled clinical trials were searched from PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Web of science without date or language limitations until September 2016. Meta-analysis was performed as recommended by the Cochrane Collaboration of trials.

RESULTS

In total 2 studies were included by strict inclusion and exclusion criteria. The result of meta-analysis showed that surgical group had a greater reduction of the primary end points (OR [0.35], 95% CI [0.15, 0.84], I = 0%) than that of the nonsurgical group.

CONCLUSION

Surgical therapy significantly lowers incidence of the primary end points (including rebleeding attack; completed stroke resulting in significant morbidity; mortality from any medical cause and requirement for bypass surgery fora nonsurgical patient as determined by a registered neurologist) compared with nonsurgical therapy. High-quality randomized controlled trials are required to confirm this conclusion.