Muscle-flap salvage of prosthetic dural repair

A critical element in the prevention of wound and cerebrospinal fluid (CSF) infections after craniotomies is the prevention of postprocedural CSF leaks. The salvage of infected prosthetic dural material in this milieu is not adequately addressed in the literature and is the subject of this study.

We performed a 7-year retrospective review of the Yale-New Haven Hospital patient records to identify successful salvage strategies in patients with relentless CSF leaks. Twenty data points were collected, including original diagnosis, nature of the procedure, presence of dural graft, definitive treatment of the leak, culture results and pre- and postoperative antibiotics.

Thirteen patients experienced post-craniotomy CSF leaks that required surgical intervention. The most common cause of the original craniotomy (54% of patients) was an oncological aetiology, followed by ruptured aneurysms or haemorrhage in 31% of the patients. Of the 13 patients experiencing CSF leaks, 76% involved the posterior skull base, and therefore a trapezius muscle flap was used in 38% of the cases. The Bovine pericardial graft (10 our of 13), a nonautologous graft, was left intact, and CSF drainage procedures were employed in most patients Growth of gram-positive organisms on cultures was found in 76% of the cases. The most frequent offenders were Staphylococcus aureus (five of the 13), coagulase-negative staphylococcal species (two out of 13), and methicillin-resistant S. aureus (two out of 13). Vancomycin was administered in all cases preoperatively. All 13 patients who underwent open surgery for CSF leak had complete resolution of the leak without need for additional reconstructive surgical intervention.

Comprehensive method of treating CSF leaks in conjunction with the salvage of bovine pericardial dural grafts may be a viable clinical option.