Selecting Substitutes for Cranial Dural Repair and Preventing Intracranial Iatrogenic Amyloid Transmission

Dural repair following an osteoplastic craniotomy presents significant challenges, necessitating an optimal dural substitute to avoid complications and ensure successful patient outcomes when primary dural closure is not possible. Ideal substitutes provide a scaffold for fibroblast migration and implantation, which are essential for achieving postoperative dural sealing and watertightness. However, such a substitute seldom exists, underscoring the importance of choosing appropriate materials for dural repair to reduce the risks of postoperative complications, including iatrogenic prion contamination that may promote intracranial amyloid transmission. Available dural substitutes are categorized into autologous, allogeneic, and xenogeneic transplants, as well as organic, synthetic, and composite polymer grafts. While each category offers specific benefits, many disadvantages persist, including the risks of prion-like amyloid protein deposition, particularly spreading iatrogenic Creutzfeldt-Jakob disease. These risks have historically been associated with the use of cadaveric dura grafts and prion-contaminated surgical instruments, necessitating safer replacement materials and enhanced sterilization protocols. This narrative review addresses the critical challenges of dural repair following cranial surgery, proposing innovative directions that include the use of composite materials and emerging technologies, such as 3D printing. Through a narrative review, the evaluation of traditional and advanced dural substitutes is provided, summarizing the advantages and limitations of currently available dural substitutes. In conclusion, the ideal dural substitute should closely replicate the natural structure of the dura, support tissue regeneration, and prevent postoperative complications such as cerebrospinal fluid leakage and intracranial iatrogenic amyloid transmission, thereby ensuring optimal patient outcomes and recovery.