Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 29  |  Issue : 3  |  Page : 637--641

Fibrin glue and fascia lata graft for management of cerebrospinal fluid leakage after cranial surgery, preliminary results


Ahmed Sh. Ammar 
 Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Correspondence Address:
Ahmed Sh. Ammar
Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, 11461
Egypt

Abstract

Objective The purpose of this study is to evaluate the efficacy of fibrin glue and fascia lata graft as a substitute for dural repair in postoperative cerebrospinal fluid (CSF) leak after cranial surgery. Background Postoperative CSF leakage is a common complication after many cranial and spinal operations. Several methods are used for repair of dural tears to stop CSF leak; one of these methods is to use fibrin glue with autologous graft - for example, fascia lata - for repair. Materials and methods A total of 12 cases with postoperative CSF leak after cranial surgery were observed and managed in the period from June 2010 to December 2012. In all, four cases were meningiomas and eight cases were gliomas. Male-to-female ratio was 5 : 7 and mean age was 56.8 years. All cases underwent secondary surgery to manage the CSF leak by fascia lata graft and fibrin glue. Mean duration of follow-up was 9.8 months (range 6-20 months). Computed tomography brain with and without contrast was performed to determine the presence of CSF leaks between 2 weeks and 3 months after surgery. Results No CSF fistula was found in all patients. No adverse effects or complications such as wound infection or neurological impairment were encountered postoperatively. Follow-up computed tomography brain revealed no evidence of CSF leakage. Conclusion The use of fascia lata graft and fibrin glue is a useful and effective method in controlling CSF leakage after cranial surgery.



How to cite this article:
Ammar AS. Fibrin glue and fascia lata graft for management of cerebrospinal fluid leakage after cranial surgery, preliminary results.Menoufia Med J 2016;29:637-641


How to cite this URL:
Ammar AS. Fibrin glue and fascia lata graft for management of cerebrospinal fluid leakage after cranial surgery, preliminary results. Menoufia Med J [serial online] 2016 [cited 2020 Apr 7 ];29:637-641
Available from: http://www.mmj.eg.net/text.asp?2016/29/3/637/198746


Full Text

 Introduction



Cerebrospinal fluid (CSF) leakage is a regular complication after most types of neurosurgical procedures [1] . Postoperative CSF leak complications, as defined by the presence of symptomatic pseudomeningocele formation or CSF leakage, present a vexing challenge for neurosurgeons after cranial or spinal operations [2] .

The incidence of CSF leaks has been variously reported as ranging from 6.2% to as high as 42% when stringent criteria, including the presence of subgaleal fluid on computed tomography (CT), are applied. The CSF leakage may be internally confined by the skin and deeper tissues, resulting in pseudomeningocele or epidural fluid collections, or manifest externally through the skin or the skull base. The latter is more dangerous because it can lead to serious infection and even death [2] .

Current methods of dural repair consist of  the application of interrupted sutures and the use of muscular fascia, periosteum, and dural replacement materials such as synthetic grafts, xenografts, or allografts, as well as other adjunctive measures, such as fibrin sealants [1] .

The tissue adhesive property of fibrinogen was first described 60 years ago. However, it was not until the availability of concentrated plasma fibrinogen and bovine thrombin that the use of fibrin sealants in surgical practice became widespread. Today, fibrin sealants are used for tissue sealing across a range of surgical procedures, including cardiothoracic, gastrointestinal, neurosurgery, and vascular surgery [3] .

The purpose of this study was to evaluate the efficacy of fascia lata graft and fibrin glue as a substitute for dural repair in postoperative CSF leak after cranial surgery.

 Materials and methods



12 cases with postoperative CSF leak after cranial surgery were observed and managed in the period from June 2010 to December 2012. (Total population of cranial surgeries in our institute in the period of study was 246 cases, incidence of CSF leak was 6.5%: '16 cases, of which four cases were post-traumatic and 12 cases was nontraumatic'. In four post-traumatic cases, CSF leak stopped spontaneously, the remaining 12 cases were studied.)

In all 12 cases, conservative measures were tried for 2 weeks before any planned surgery, and CSF leak persisted despite conservative trials.

Four cases were meningiomas (three parasagittal and one convexity meningioma) and eight cases were gliomas (glioblastoma).

Male-to-female ratio was 7 : 5 and mean age was 56.8 years.

The primary surgery for all cases was total macroscopic excision for meningioma cases (n = 4) and near total excision for glioma cases (n = 8).

In meningioma cases, dural excision was performed for all cases with dural grafting by autologous dural graft (three pericranial grafts and one temporalis fascia graft).

In glioma cases, autologous grafting by pericranial graft was performed in all cases (n = 8).

In all cases, the CSF leak was observed during the first week after surgery (mean 4 days), and conservative measures were tried for 2 weeks before any planned surgery.

MRI brain was performed for every case during the first 2 weeks after the initial surgery to demonstrate the possible site of leak, radiological signs of increased intracranial pressure, and any tumor remnants not removed during the primary surgery.

Surgical technique

All cases underwent secondary surgery to manage the CSF leak by fascia lata graft and fibrin glue. First, the site of leak was identified and approximated by direct 4/0 silk sutures, and fibrin glue was then applied directly over the site of leakage. A fascia lata autologous graft was obtained from the donor site (lateral aspect of the thigh) and applied as on lay graft over the site of the leak and fixed in place by few widely spaced interrupted 4/0 silk sutures, and then fibrin glue was applied to tightly fix the graft to the underlying dura or old graft. If direct approximation of the defect cannot be done, the fascia lata graft was sutured directly to the edge of the defect, and fibrin glue was applied to tighten the dura-graft interface. Valsalva maneuver was applied to elevate intracranial tension to ensure tight adhesion of the fascia lata graft to the underlying tissue and to ensure that no any CSF leak could be observed. In all cases, fibrin glue is the superadded factor. An autologous graft was applied in the primary operation, which does not prevent CSF leak. In addition, sutures that were placed during secondary surgery were just widely separated for approximation and were not expected to prevent CSF  leak.

Postoperative period

All patients were kept with head off the bed in a 45° position, with wound dressing every 2 days. Prophylactic antibiotics were given for 7 days postoperatively. Dehydrating measures for 2 days were applied for all patients.

Follow-up

The mean duration of follow-up was 9.8 months (range: 6-20 months). CT brain with and without contrast was performed for all cases to determine the presence of CSF leaks between 2 weeks and 3 months after surgery. Extradural fluid collection appearing as an area of low density at the site of surgery in CT brain was considered as CSF leakage.

 Results



In all patients, the CSF leak was managed by fascia lata graft and fibrin glue. No CSF fistula was found in all patients. No adverse effects or complications such as wound infection or neurological impairment were encountered postoperatively. Follow-up CT brain imaging revealed no evidence of CSF leak ([Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7] and [Table 1]).{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Table 1}

 Discussion



The incidence of CSF leaks had been variously reported as ranging from 6.2% to as high as 42% [2] . The incidence of postoperative CSF leaks after supratentorial approaches can be as high as 1.2-10.9% [4],[5] .

Postoperative CSF leakage and collection increases the potential risk of persistent CSF fistulas, meningitis, subcutaneous, graft bone, or epidural infections, as well as subdural hematoma [6] .

Patients with cranial CSF leaks have a 10% risk of developing meningitis per year, and if cranial leaks last more than 7 days the chances of developing meningitis are significantly higher [7] .

Meningitis is more common with spontaneous fistula. Risk may be higher in postneurosurgical CSF fistula than in post-traumatic fistula because elevated intracranial pressure is common in the latter (forces CSF outward). If the site of leak is unidentified before attempted surgical treatment, 30% develop a recurrent leak postsurgery, with 5-15% of these developing meningitis before the leak is stopped. Meningitis may promote inflammatory changes at the site of the leak, with a resultant cessation of the leak [8] .

Orthostatic hypotension is another complication that occurs because of autonomic dysfunction when blood pressure drops significantly. The autonomic dysfunction is caused by compression of the brainstem, which controls breathing and circulation [9] .

There are documented cases of reversible frontotemporal dementia and coma [10] .

Coma due to a CSF leak has been successfully treated by using blood patches and/or fibrin glue and by placing the patient in the Trendelenburg position [11] .

The ideal dural substitute would maintain its integrity as a tissue layer but would not be excessively adherent to pia mater with low incidence of infection. Most of the materials used have deficiencies in this regard [12] . Cadaveric dural allograft has a risk of viral infection, including Creutzfeldt-Jakob disease [13] . Synthetic materials - for example, expanded polytetrafluoroethylene sheet (Gore-Tex augmentation material) - is commonly used as a substitute and is available in any size or shape; however, it is associated with an increased risk of bacterial infection and adhesion [14] .

Autografts have long been considered the ideal choice, as they are infection free, have a similar characteristic to dura, and are well received by the host. Fascia lata graft (extracted from the thigh) costs a little more operative time and perhaps slightly increased morbidity, but it is much cheaper than any dural substitutes, and thus we choose that method for repair of CSF leaks in our cases. Although we tried to save by using facia lata but fibrin glue is rather expensive. In our cases, fibrin glue was obtained by insurance or governmental expense.

Fibrin glue can be used for hemostasis, as a bioadhesive and fixative of injured tissue. The advantage of fibrin glue is the composition of human plasma protein, which may generate fewer immune reactions compared with other surgical materials such as gelatin sponges, oxidized cellulose, or microfibrillar collagen. Therefore, fibrin glue has recently been used in various neurosurgical procedures including cranial bone plasty, nerve suture, hemostasis on the dural sinus, as a supporter of inserted materials, and especially for the prevention of CSF leakage through dural sutures [6] .

The fibrin sealants comprise purified, virus-inactivated human fibrinogen, human thrombin, and sometimes added components, such as virus-inactivated human factor XIII and bovine aprotinin. These agents mimic the final steps of the physiological coagulation cascade to form a fibrin clot. The use of any plasma-derived product in the surgical setting carries a potential risk of viral transmission. In fact, it was the risk of viral transmission from fibrinogen and thrombin that halted development work on fibrin sealants in the USA. Since that time, new techniques for isolating and concentrating plasma fractions have been developed, and national and international guidelines have been introduced to ensure the safety of all plasma products. All plasma donors are carefully selected and their plasma units screened for viral contamination before processing. All plasma donations and bovine tissue used in the production of commercial fibrin sealants undergo rigorous viral reduction/elimination steps. As a result of this carefully controlled and monitored process, there have been no proven cases of viral transmission associated with the use of commercial fibrin sealant [15] .

Despite the lack of Federal Drug Administration approval, Tisseel (fibrin glue) has seen wide adoption in 'off-label' use. DuraSeal (polyethylene glycol hydrogel [Confluent Surgical Inc., Waltham, Massachusetts, USA]), which is Federal Drug Administration approved, was associated with two instances of paralysis. Alternatively, Bioglue (glutaraldehyde, bovine albumin [Cryolife, Kennesaw, Georgia, USA]) was described as neurotoxic even by the manufacturer [16] .

All our cases underwent autologous grafting during the initial (pre CSF leak) surgery, as well as during repair of CSF leak, but the superadded factor in our study is the use of fibrin sealants. All cases had no postoperative CSF leakage after using fibrin glue.

In 2006, Shimada et al. [12] used bioabsorbable polyglycolic acid mesh and fibrin glue as a substitute for dural repair in cases of post-spinal-surgery CSF leak, and all their cases (10 cases) were also treated successfully, although the velocity of CSF flow in the spine is higher than in the cerebral lesions, being especially high in the cervical spine. Therefore, we agree with others [2,3,12] that fibrin glue sealants are useful for the prevention of CSF leakage.

This study is limited by the small number of cases that may skew conclusion, as well as the economic influence (costs of fibrin glue and MRI for follow-up that could not be done), and thus further studies with more cases and continuous follow-up of CSF leakage using MRI are needed to evaluate the effectiveness of fibrin glue for repair of post-cranial-surgery CSF  leakage.

 Conclusion



Fascia lata autologous graft with fibrin glue sealants in the treatment of postoperative CSF leakage after cranial surgery is an effective method with excellent surgical results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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