Prevention of postoperative cerebrospinal fluid leaks with multilayered reconstruction using titanium mesh–hydroxyapatite cement cranioplasty after translabyrinthine resection of acoustic neuroma

Technical note

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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).

Article Information

Address correspondence to: Nicholas C. Bambakidis, M.D., Department of Neurological Surgery, The Neurological Institute, University Hospitals Case Medical Center, Cleveland, Ohio 44106. email:

Please include this information when citing this paper: published online January 25, 2013; DOI: 10.3171/2012.11.JNS121365.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Intraoperative photographs showing the surgical technique of wound closure following TLAN. A: Bone wax (black arrow) is applied to the posterior epitympanum to seal off the pathway to the middle ear. B: A temporalis fascia graft is placed over a layer of Duragen and TISSEEL sealant, which is applied initially over the internal auditory canal (IAC) dural and posterior fossa defect. C: TISSEEL fibrin sealant is again applied over the temporalis fascia to ensure a watertight closure. D: A piece of titanium mesh, which is secured with screws, holds all these layers down and helps to push them over the dural defect. E: A layer of HAC is applied over the mesh to provide excellent contour with the adjacent cortex. FN = facial nerve; IAC = internal auditory canal.

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    Computed tomography scan demonstrating symmetric contouring of the surgically treated left mastoid cortex compared with the contralateral side. The arrow indicates hydroxyapatite.

  • View in gallery

    Illustration of the multilayer closure of a translabyrinthine wound using HAC and titanium mesh cranioplasty showing the surgical bed after resection of a tumor from the IAC (A), layering of temporalis fascia (B), use of dural sealant for watertight dural closure (C), free fat graft placement in the mastoid bowl (D), titanium mesh placed over the depressed fat graft (E), and HAC layered over the mesh prior to layered skin closure (F). EAC = external auditory canal; SS = sigmoid sinus. Copyright 2012 Maroun T. Semaan.

  • View in gallery

    Postoperative MR images obtained 1 month (left) and 12 months (right) after surgery showing minimal changes to the fat graft (asterisk) with no significant resorption. The dural defect, which had been reestablished using fascia and DuraGen, appears smooth and in continuity with the native dura. There are no signs of CSF accumulation in the wound area. The arrows indicate the reconstructed dural defect.



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