Several prophylactic surgical methods have been tried to prevent CSF leakage after translabyrinthine resection of acoustic neuroma (TLAN). The authors report an improvised technique for multilayer watertight closure using titanium mesh–hydroxyapatite cement (HAC) cranioplasty in addition to dural substitute and abdominal fat graft after TLAN.
The study was limited to 42 patients who underwent TLAN at University Hospitals Case Medical Center using this new technique from 2006 to 2012. Systematic closure of the surgical wound in layers using temporalis fascia, dural substitute, dural sealant, adipose graft, titanium mesh, and then HAC was performed in each case. Temporalis muscle and eustachian tube obliteration were not used. The main variables studied were patient age, tumor size, tumor location, cosmetic outcome, length of hospitalization, and the incidence of CSF leak, pseudomeningocele, and infection.
Excellent cosmetic outcome was achieved in all patients. There were no cases of postoperative CSF rhinorrhea, incisional CSF leak, or meningitis. Cosmetic results were comparable to those achieved using HAC alone. This cost-effective technique used only a third of the HAC required for traditional closure in which the entire mastoid defect is filled with cement, predisposing to infection. Postoperative CT and MRI showed excellent bony contouring and dural reconstitution, respectively.
The authors report on successful use of titanium mesh–HAC cranioplasty in preventing postoperative CSF leak after TLAN in all cases in their series. The titanium mesh provides a well-defined anatomical dissection plane that would make reoperation easier than working through scarred soft tissue. The mesh bolsters the fat graft and keeps HAC out of direct contact with mastoid air cells, thereby reducing the risk of infection. The cement cranioplasty does not preclude subsequent implantation of a bone-anchored hearing aid.
Abbreviations used in this paper:HAC = hydroxyapatite cement; TLAN = translabyrinthine resection of acoustic neuroma (vestibular schwannoma).
Address correspondence to: Nicholas C. Bambakidis, M.D., Department of Neurological Surgery, The Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio 44106. email: Nicholas.Bambakidis2@UHhospitals.org.
Please include this information when citing this paper: published online January 25, 2013; DOI: 10.3171/2012.11.JNS121365.
ArensSSchlegelUPrintzenGZieglerWJPerrenSMHansisM: Influence of materials for fixation implants on local infection. An experimental study of steel versus titanium DCP in rabbits. J Bone Joint Surg Br78:647–6511996
BairdCJHdeibASukIFrancisHWHollidayMJTamargoRJ: Reduction of cerebrospinal fluid rhinorrhea after vestibular schwannoma surgery by reconstruction of the drilled porus acusticus with hydroxyapatite bone cement. J Neurosurg107:347–3512007
BrennanJWRowedDWNedzelskiJMChenJM: Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg94:217–2232001
GonzalezLFLekovicGPKakarlaUKReisCVCWeiskopfPDaspitCPSurgical approaches to the cerebellopontine angle. BambakidisNCMegerianCASpetzlerRF: Surgery of the Cerebellopontine AngleShelton, CTBC Decker2009. 53–72
KamyszekTWeiheSScholzMWehmöllerMEufingerH: [Management of craniofacial bone defects with individually prefabricated titanium implants. Follow-up and evaluation of 78 patients with 78 titanium implants 1994–1998]. Mund Kiefer Gesichtschir5:233–2382001. (Ger)
NakamuraMTamakiNHaraYNagashimaTTamuraS: Use of a split bone graft to correct the cosmetic deformity associated with the transpetrosal-transtentorial surgical approach: technical report. Neurosurgery40:1089–10911997
StieglitzLHGiordanoMGerganovVRaabeASamiiASamiiM: Petrous bone pneumatization is a risk factor for cerebrospinal fluid fistula following vestibular schwannoma surgery. Neurosurgery67:2 Suppl Operative509–5152010