Eosinophilic meningitis following suboccipital craniotomy without bovine dural graft: illustrative case

BACKGROUND Eosinophilic meningitis is a rare known complication after brain surgery associated with duraplasty using artificial bovine graft. However, eosinophilic meningitis after craniotomy without bovine dural graft has not been reported. OBSERVATIONS A 48-year-old female presented with lateral medullary infarction caused by a vertebral artery dissecting aneurysm incorporating the posterior inferior cerebellar artery (PICA). The authors performed occipital artery–PICA anastomosis and repaired the dura by primary suture without bovine graft. Thereafter, endovascular internal trapping using coils was conducted. Severe headache developed at postoperative day 17, and the patient was diagnosed with eosinophilic meningitis. After administration of a high-dose corticosteroid for 2 weeks, her symptoms and laboratory findings were improved. LESSONS Postoperative eosinophilic meningitis is rarely related to craniotomy without using bovine graft. Neurosurgeons should consider the possibility of eosinophilic meningitis after craniotomy without a xenogeneic dural material.

Outcomes for various dural graft materials after posterior fossa decompression with duraplasty for Chiari malformation type I: a systematic review and meta-analysis

OBJECTIVE Posterior fossa decompression with duraplasty (PFDD) is often used for Chiari malformation type I (CM-I), but outcomes associated with different dural graft materials are not well characterized. In this meta-analysis, the authors examined complication rates and outcomes after PFDD for CM-I for autografts and four types of nonautologous grafts. METHODS A literature search of numerous electronic databases (Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, NHS Economic Evaluation Database, and ClinicalTrials.gov) was performed to identify articles detailing complications for dural graft materials after PFDD. Whenever available, data were also extracted regarding the need for revision surgery, symptom changes after PFDD, and syrinx size changes after PFDD. All searches were compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Institute of Medicine, Standards for Systematic Reviews, Cochrane Handbook for Systematic Reviews of Interventions, and Peer Review of Electronic Search Strategies guidelines. There were no exclusion criteria based on patient age or presence or absence of syringomyelia. RESULTS The current evidence surrounding outcomes for various dural graft materials was found to be of low or very low quality. Twenty-seven studies were included, encompassing 1461 patients. Five types of dural graft materials were included: autograft (n = 404, 27.6%), synthetic (n = 272, 18.6%), bovine pericardium (n = 181, 12.4%), collagen-based (n = 397, 27.2%), and allograft (n = 207, 14.2%). Autograft was associated with a significantly lower rate of pseudomeningocele compared to collagen-based grafts, allografts, and nonautologous grafts in aggregate. Autograft was also associated with the lowest rates of aseptic meningitis, infectious meningitis, and need for revision PFDD, though these associations did not reach statistical significance. No other graft comparisons yielded significant results. Autograft and nonautologous graft materials yielded similar rates of revision surgery and produced similar improvements in postoperative symptoms and syrinx size. CONCLUSIONS Autograft was the dural graft material that most frequently had the lowest rate of complications and was associated with significantly lower rates of pseudomeningocele compared to collagen-based graft, allograft, and nonautologous graft materials. Autografts and nonautologous grafts yielded similar outcomes for revision surgery, symptoms, and syrinx size. Large prospective studies comparing different graft materials are needed to accurately and precisely characterize outcomes for individual graft types.

Reconstructive Outcomes of Multilayered Closure of Large Skull Base Dural Defects Following Open Anterior Craniofacial Resection

Background Standardized reconstruction protocols for large open anterior skull base defects with dural resection are not well described. Here we report the outcomes and technique of a multilayered reconstructive algorithm utilizing local tissue, dural graft matrix, and microvascular free tissue transfer (MVFTT) for reconstruction of these deformities. Design This study is a retrospective review. Results Eleven patients (82% males) met inclusion criteria, with five (45%) having concurrent orbital exenteration and eight (73%) requiring maxillectomy. All patients required dural resection with or without intracranial tumor resection, with the average dural defect being 36.0 ± 25.9 cm2. Dural graft matrices and pericranial flaps were used for primary reconstruction of the dural defects, which were then reinforced with free fascia or muscle overlay by means of MVFTT. Eight (73%) patients underwent anterolateral thigh MVFTT, with the radial forearm, fibula, and vastus lateralis comprising the remainder. Average total surgical time of tumor resection and reconstruction was 14.9 ± 3.8 hours, with median length of hospitalization being 10 days (IQR: 9.5, 14). Continuous cerebrospinal fluid drainage through a lumber drain was utilized in 10 (91%) patients perioperatively, with an average length of indwelling drain of 5 days. Postoperative complications occurred in two (18%) patients who developed asymptomatic pneumocephalus that resolved with high-flow oxygen therapy. Conclusion A standardized multilayered closure technique of dural graft matrix, pericranial flap, and MVFTT overlay in the reconstruction of large open anterior craniofacial dural defects can assist the reconstructive team in approaching these complex deformities and may help prevent postoperative complications.

A Randomised Interventional Study to Compare Autologous and Nonautologous Dural Substitutes Among Traumatic Brain Injury (TBI) Patients

Objectives To determine and compare the effectiveness and safety of galea-pericranium autologous dural graft with nonautologous polypropylene (G-patch) dural substitute among traumatic brain injury (TBI) patients. Methods A prospective interventional randomized comparative study was conducted at the Department of Neurosurgery from November 2013 to March 2015 after obtaining approval from the Institutional Ethical Committee. The study population included 50 cases of TBI which were divided into two groups of 25 each by the randomization technique and were treated either with autologous duraplasty (galea-pericranium) or nonautologous polypropylene (G-patch) dural substitute. The outcomes measured were time to duraplasty, blood loss, hospital stay, and the incidence of complications with the two techniques. The data were entered in a MS Excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. A p value of < 0.05 was considered statistically significant. Results The average time to harvest galea-pericranium was 5 minutes. Compared with the patients undergoing G-patch, the patients in group pericranium had comparable duraplasty time (minutes) (34.32 vs. 27.80, p = 0.44), significantly lower drain output (54.8 vs. 74.5, p = 0.017), comparable blood loss (322 vs. 308, p = 0.545), comparable blood transfusion (24% vs. 16%, p = 0.48), significantly lesser duration of hospital stay (8.6 vs. 10.44, p = 0.028), comparable wound infection (8% vs. 16%, p = 0.384), and comparable cerebrospinal fluid (CSF) leak (0% vs. 8%, p = 0.149). Conclusion The study showed that galea-pericranium and polypropylene dural patch are equally effective and safe dural substitutes in providing a dural seal to minimize the CSF leaks and infections among posttraumatic brain injury patients.

Local Tolerance and Biodegradability of a Novel Artificial Dura Mater Graft Following Implantation Onto a Dural Defect in Rabbits

Dura mater defects are a common problem following neurosurgery. Dural grafts are used to repair these defects; among them are biodegradable polymeric synthetic grafts. ArtiFascia is a novel synthetic and fibrous Dural graft, composed of poly(l-lactic-co-caprolactone acid) (PLCL) and poly(d-lactic-co-caprolactone acid). In this study, the biodegradability and local tolerance of ArtiFascia was evaluated in rabbits and compared with a bovine collagen matrix as a reference control. ArtiFascia implantation resulted in the formation of neo-dura at the site of implantation and recovery of the dural damage and the calvaria bone above. The implanted graft was completely absorbed after 12 months and the remaining macrophages were morphologically consistent with the anti-inflammatory M2-like phenotype, which contributes to tissue healing and are not pro-inflammatory. The site of the drilled skull bone had a continuous smooth surface, without exuberant tissue or inflammation and a newly formed trabecular bone formation indicated the healing process of the bone. These results support the local tolerability and biodegradability of ArtiFascia when used as a dural graft in rabbits. This study suggests that PLCL-based grafts including ArtiFascia are safe and effective to repair Rabbit Dura.

Incidence of complications following non-watertight dural reconstruction with a non-suturable, absorbable collagen matrix onlay graft in elective cranial surgery

Background: Collagen matrices are effective duraplasty grafts with increasing acceptability. However, little evidences exits for dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Purpose of our retrospective analysis was to advance our understanding of the use of semisynthetic collagen as dural substitute in elective cranial surgery.Methods: A consecutive series of sixty patients who underwent elective cranial surgery, where non-watertight dural reconstructions were done with a non-suturable, absorbable collagen matrix onlay graft, has been analysed retrospectively.Results: Overall, the most common indication for duraplasty was tumor resection (93.3%). CSF leak rate was 10.0%. Incidence of aseptic meningitis was 8.3% and all cases has been resolved with steroids alone. Similarly, postoperative surgical site infection rate was 8.3%. Incidence of pseudomeningocele in follow-up was 6.7%. Only in one case (1.7%), permanent CSF (cerebrospinal fluid) diversion was needed due to troublesome CSF leak with associated hydrocephalus.Conclusions: Semisynthetic, monolayer collagen matrix used as an onlay dural graft is a simple, yet an attractive alternative in duraplasty due to their easy handling, lower surgical time, and high biocompatibility, where primary dural closure is undesirable or not feasible. Our study provides greater insight into non-water tight duraplasty procedure. However, further study is needed to determine the optimal strategy for dural reconstruction. Data from this study may be used to compare alternative methods of dural reconstruction in elective cranial surgery.

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

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

Fetal Bovine Collagen Grafts for Repair of Tegmen Defects and Encephaloceles Via Middle Cranial Fossa Approach

To evaluate the use of commercially available allogenic dural graft materials made of fetal bovine collagen, we present an analysis of our case series with use of autologous and allogenic graft materials. Patients who underwent surgical repair of a tegmen tympani defect associated with ipsilateral conductive hearing loss and cerebrospinal fluid (CSF) otorrhea using a middle cranial fossa (MCF) approach from 2004 to 2018 at Loyola University Medical Center were included. Resolution of CSF otorrhea, audiologic outcomes, facial nerve preservation, and surgical complications was analyzed. Thirty-three patients with an average age of 55.3 years (range: 21-78, standard deviation [SD]: 12.9) and body mass index of 34.4 (range: 22-51, SD: 7.4) underwent an MCF repair of a tegmen and dural defect. All patients presented with CSF otorrhea and conductive hearing loss ipsilateral to the defect. Repairs were made with combinations of allograft and autograft in 17 cases, allograft only in 15 cases, and autograft only in 5 cases. Improvement in hearing was noted in 33 cases, and resolution of CSF otorrhea was noted in 36 cases; one patient required repeat surgery which resolved CSF otorrhea. Three patients had minor complications; all these were in the autograft group. The MCF approach coupled with the use of fetal bovine collagen grafts is a safe and viable method to repair tegmen tympani and associated dural defects with salutary outcomes and low morbidity.

Resection of a Recurrent Cervicomedullary Junction Fibromyxoid Sarcoma through a Far Lateral Approach

Objectives This study describes a far lateral approach for the resection of a recurrent fibromyxoid sarcoma involving the ventrolateral brainstem, with emphasis on the microsurgical anatomy and technique. Design A far lateral craniotomy is performed in the lateral decubitus position and the transverse and sigmoid sinuses exposed. After opening the dura, sutures are placed to allow gentle mobilization of the sinuses. The recurrent tumor is immediately visible. The involved dura is resected and aggressive internal debulking is performed. Subarachnoid dissection gives access to the lower cranial nerves. The tumor is dissected off the affected portions of the brainstem. A dural graft is used to reconstitute the dura. Photographs of the region are borrowed from Dr. Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior author performed the surgery. The video was edited by Dr. V.N. chart review, and literature review were performed by Drs. W.M. and J.B. Outcome measures Outcome was assessed with the extent of resection and postoperative neurological function. Results A near gross total resection of the lesion was achieved. The patient developed a left vocal cord paresis, but her voice was improving at 3-month follow-up. Conclusion Understanding the microsurgical anatomy of the craniocervical junction and ventrolateral brainstem and meticulous microneurosurgical technique are necessary to achieve adequate resection of lesions involving the ventrolateral brainstem. The far lateral approach provides an adequate corridor to this region.The link to the video can be found at: https://youtube/uYEhgPbgrTs.