Intraoperative Agents for Hemostasis and Dural Reconstruction in Neurosurgery

Intraoperative hemostasis and dural closure are critical components of neurosurgical procedures, directly affecting operative time, blood loss, neurological outcomes, and the risk of cerebrospinal fluid leak, infection, and reoperation. Over the past 2 decades, there has been rapid expansion in the availability of hemostatic adjuncts, dural substitutes, and liquid sealants. Despite widespread adoption, product selection is frequently guided by surgeon preference and institutional practice rather than a detailed understanding of material composition, mechanism of action, and product-specific limitations. This qualitative review provides a neurosurgery-focused, product-level comparison of commonly used intraoperative hemostatic agents, dural substitutes, and dural sealants, with emphasis on composition, mechanism of action, indications, advantages, limitations, safety considerations, and cost. A comprehensive literature search was conducted using PubMed, Embase, United States Food and Drug Administration device summaries, manufacturer instructions for use, and key clinical trials and observational studies. Products were categorized into 3 groups: intraoperative hemostatic adjuncts, dural substitutes and graft materials, and liquid dural sealants and adhesives. The review encompasses gelatin-based products, oxidized regenerated cellulose, collagen-based agents, flowable gelatin-thrombin matrices, topical thrombin preparations, autologous and nonautologous dural grafts, and fibrin- and polyethylene glycol-based sealants. Selection of these materials should be guided by anatomic considerations, patient-specific factors, and best available evidence. This review serves as a practical reference to support informed intraoperative decision-making in neurosurgical practice.