Reconstruction after retrosigmoid approaches using autologous fat graft-assisted Medpor Titan cranioplasty: assessment of postoperative cerebrospinal fluid leaks and headaches in 60 cases

Abstract

Our multilayer repair technique with a fat graft-assisted Medpor Titan cranioplasty appears effective in preventing postoperative CSF leaks and new-onset postoperative headaches after retrosigmoid approaches. Postoperative lumbar drainage may not be necessary.

A Multilayered Technique for Repair of the Suboccipital Retrosigmoid Craniotomy

“…Additionally, a multilayered soft tissue closure may also be an important factor in reducing the risk of postoperative headaches, since the posterior fossa dura and suboccipital muscles are rich in blood supply and innervation. 11,15 In our series, 2 of 25 patients (8%) reported persistent postoperative headaches during the mean follow-up period of 16 months, with an average severity of 6/10 on the visual analog scale. This is consistent with previous reports (►Table 1) and suggests that a repair technique that reestablishes anatomic separation between the dura and extracranial soft tissues may be an important factor.…”

“…[4][5][6][7]9 Prevention of CSF leak is extremely important, as it increases the risk of meningitis and often requires additional procedures such as percutaneous drainage of pseudomeningoceles, lumbar drain insertion, and surgical reexploration. 11,12 To address this complication, many authors have described reconstruction techniques that focus on achieving a watertight dural closure. For example, Samii et al reported a 2% incidence of CSF leak in a series of 200 patients closed with primary dural closure along with a pericranial flap.…”

“…10,14 Current theories to explain the underlying pathophysiology of these headaches include (1) excessive dural stretch and tension, (2) myocutaneous-dural scarring secondary to loss of normal tissue barriers, and (3) dural irritation secondary to the use of sealants such as fibrin glue. 10,11,[14][15][16] Many authors have proposed techniques to ameliorate these possible underlying mechanisms with some success. For example, some authors have advocated the use of bone cranioplasty, methymethacrylate cranioplasty, hydroxyapatite cranioplasty, or titanium mesh, reporting headache incidence ranging from 0 to 9%.…”

Surgical Nuances to Reduce and Manage Cerebrospinal Fluid Leaks after Microvascular Decompression

“…The cranioplasty for bone defects is also crucial for preventing CSF leaks. As mentioned above, the CSF leakage was significantly lower in the group that filled bone defects using bone cement than titanium mesh [7,[16][17][18]. However, fat graft-assisted titanium cranioplasty could also prevent postoperative CSF leak [17].…”

“…As mentioned above, the CSF leakage was significantly lower in the group that filled bone defects using bone cement than titanium mesh [7,[16][17][18]. However, fat graft-assisted titanium cranioplasty could also prevent postoperative CSF leak [17]. While the rigid titanium mesh maintains its contour after closing the scalp, the dead space between the dura suture site and mesh may also cause a driving force of negative pressure to make CSF leak at the dural closure site.…”