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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Object

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.

Methods

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.

Results

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.

Conclusions

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: Nicholas.Bambakidis2@UHhospitals.org.

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.

Headings

Figures

  • 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.

  • View in gallery

    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.

References

1

Arens SSchlegel UPrintzen GZiegler WJPerren SMHansis M: Influence of materials for fixation implants on local infection. An experimental study of steel versus titanium DCP in rabbits. J Bone Joint Surg Br 78:6476511996

2

Arriaga MAChen DA: Hydroxyapatite cement cranioplasty in translabyrinthine acoustic neuroma surgery. Otolaryngol Head Neck Surg 126:5125172002

3

Arriaga MAChen DABurke EL: Hydroxyapatite cement cranioplasty in translabyrinthine acoustic neuroma surgery— update. Otol Neurotol 28:5385402007

4

Ascherman JAFoo RNanda DParisien M: Reconstruction of cranial bone defects using a quick-setting hydroxyapatite cement and absorbable plates. J Craniofac Surg 19:113111352008

5

Baird CJHdeib ASuk IFrancis HWHolliday MJTamargo RJ: Reduction of cerebrospinal fluid rhinorrhea after vestibular schwannoma surgery by reconstruction of the drilled porus acusticus with hydroxyapatite bone cement. J Neurosurg 107:3473512007

6

Bambakidis NCMegerian CASpetzler RF: Surgery of the Cerebellopontine Angle Shelton, CTBC Decker2009

7

Bambakidis NCMunyon CKo ASelman WRMegerian CA: A novel method of translabyrinthine cranioplasty using hydroxyapatite cement and titanium mesh: a technical report. Skull Base 20:1571612010

8

Becker SSJackler RKPitts LH: Cerebrospinal fluid leak after acoustic neuroma surgery: a comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches. Otol Neurotol 24:1071122003

9

Blake GBMacFarlane MRHinton JW: Titanium in reconstructive surgery of the skull and face. Br J Plast Surg 43:5285351990

10

Brennan JWRowed DWNedzelski JMChen JM: Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment. J Neurosurg 94:2172232001

11

Bryce GENedzelski JMRowed DWRappaport JM: Cerebrospinal fluid leaks and meningitis in acoustic neuroma surgery. Otolaryngol Head Neck Surg 104:81871991

12

Cabraja MKlein MLehmann TN: Long-term results following titanium cranioplasty of large skull defects. Neurosurg Focus 26:6E102009

13

Celikkanat SMSaleh EKhashaba ATaibah ARusso AMazzoni A: Cerebrospinal fluid leak after translabyrinthine acoustic neuroma surgery. Otolaryngol Head Neck Surg 112:6546581995

14

Chang CCMerritt K: Infection at the site of implanted materials with and without preadhered bacteria. J Orthop Res 12:5265311994

15

Chen TCMaceri DRLevy MLGiannotta SL: Brain stem compression secondary to adipose graft prolapse after translabyrinthine craniotomy: case report. Neurosurgery 35:5215241994

16

Cordero JMunuera LFolgueira MD: Influence of metal implants on infection. An experimental study in rabbits. J Bone Joint Surg Br 76:7177201994

17

Costantino PDHiltzik DHSen CFriedman CDKveton JFSnyderman CF: Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement. Arch Otolaryngol Head Neck Surg 127:5885932001

18

Couldwell WTFukushima T: Cosmetic mastoidectomy for the combined supra/infratentorial transtemporal approach. Technical note. J Neurosurg 79:4604611993

19

Day JDChen DAArriaga M: Translabyrinthine approach for acoustic neuroma. Neurosurgery 54:3913962004

20

Ducic Y: Titanium mesh and hydroxyapatite cement cranioplasty: a report of 20 cases. J Oral Maxillofac Surg 60:2722762002

21

Eufinger HWehmöller M: Individual prefabricated titanium implants in reconstructive craniofacial surgery: clinical and technical aspects of the first 22 cases. Plast Reconstr Surg 102:3003081998

22

Falcioni MMulder JJTaibah ADe Donato GSanna M: No cerebrospinal fluid leaks in translabyrinthine vestibular schwannoma removal: reappraisal of 200 consecutive patients. Am J Otol 20:6606661999

23

Fayad JNSchwartz MSSlattery WHBrackmann DE: Prevention and treatment of cerebrospinal fluid leak after translabyrinthine acoustic tumor removal. Otol Neurotol 28:3873902007

24

Fishman AJMarrinan MSGolfinos JGCohen NLRoland JT Jr: Prevention and management of cerebrospinal fluid leak following vestibular schwannoma surgery. Laryngoscope 114:5015052004

25

Fukushima TCombined supra- and infra-parapetrosal approach for petroclival lesions. Sekhar LNJanecka IP: Surgery of Cranial Base Tumors New YorkRaven Press1993. 661670

26

Gal TJBartels LJ: Use of bone wax in the prevention of cerebrospinal fluid fistula in acoustic neuroma surgery. Laryngoscope 109:1671691999

27

Gillman GSParnes LS: Acoustic neuroma management: a six-year review. J Otolaryngol 24:1911971995

28

Goddard JCOliver ERLambert PR: Prevention of cerebrospinal fluid leak after translabyrinthine resection of vestibular schwannoma. Otol Neurotol 31:4734772010

29

Gonzalez LFLekovic GPKakarla UKReis CVCWeiskopf PDaspit CPSurgical approaches to the cerebellopontine angle. Bambakidis NCMegerian CASpetzler RF: Surgery of the Cerebellopontine Angle Shelton, CTBC Decker2009. 5372

30

Hardy DGMacfarlane RBaguley DMoffat DA: Surgery for acoustic neurinoma. An analysis of 100 translabyrinthine operations. J Neurosurg 71:7998041989

31

Hillman TAShelton C: Resorbable plate cranioplasty after the translabyrinthine approach. Otol Neurotol 32:117111742011

32

Hoffman RA: Cerebrospinal fluid leak following acoustic neuroma removal. Laryngoscope 104:40581994

33

House WFHitselberger WE: Transtemporal bone microsurgical removal of acoustic neuromas. Total versus subtotal removal of acoustic tumors. Arch Otolaryngol 80:7517521964

34

Joffe JHarris MKahugu FNicoll SLinney ARichards R: A prospective study of computer-aided design and manufacture of titanium plate for cranioplasty and its clinical outcome. Br J Neurosurg 13:5765801999

35

Kamyszek TWeihe SScholz MWehmöller MEufinger H: [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 Gesichtschir 5:2332382001. (Ger)

36

Khrais THFalcioni MTaibah AAgarwal MSanna M: Cerebrospinal fluid leak prevention after translabyrinthine removal of vestibular schwannoma. Laryngoscope 114:101510202004

37

Kruger EAArriaga MAChen DHillman T: Acoustic neuroma surgery: hydroxyapatite cement cranioplasty. Otolaryngol Head Neck Surg 139:2 Suppl 11562008. (Abstract)

38

Kshettry VRHardy SWeil RJAngelov LBarnett GH: Immediate titanium cranioplasty after debridement and craniectomy for post-craniotomy surgical site infection. Neurosurgery 70:8142011

39

Kwartler JASchulder MBaredes SChandrasekhar SS: Endoscopic closure of the eustachian tube for repair of cerebrospinal fluid leak. Am J Otol 17:4704721996

40

Mass SCWiet RJDinces E: Complications of the translabyrinthine approach for the removal of acoustic neuromas. Arch Otolaryngol Head Neck Surg 125:8018041999

41

Matsuno ATanaka HIwamuro HTakanashi SMiyawaki SNakashima M: Analyses of the factors influencing bone graft infection after delayed cranioplasty. Acta Neurochir (Wien) 148:5355402006

42

Merkus PTaibah ASequino GSanna M: Less than 1% cerebrospinal fluid leakage in 1,803 translabyrinthine vestibular schwannoma surgery cases. Otol Neurotol 31:2762832010

43

Nakamura MTamaki NHara YNagashima TTamura S: Use of a split bone graft to correct the cosmetic deformity associated with the transpetrosal-transtentorial surgical approach: technical report. Neurosurgery 40:108910911997

44

Ota TKamada KSaito N: Repair of cerebrospinal fluid leak via petrous bone using multilayer technique with hydroxyapatite paste. World Neurosurg 74:6506532010

45

Penholz H: Development and present state of cerebellopontine angle surgery from the neuro- and otosurgical point of view. Arch Otorhinolaryngol 240:1641741984

46

Pulec JL: Technique to avoid cerebrospinal fluid otorhinorrhea with translabyrinthine removal of acoustic neuroma. Laryngoscope 104:3823861994

47

Ridenour JSPoe DSRoberson DW: Complications with hydroxyapatite cement in mastoid cavity obliteration. Otolaryngol Head Neck Surg 139:6416452008

48

Rodgers GKLuxford WM: Factors affecting the development of cerebrospinal fluid leak and meningitis after translabyrinthine acoustic tumor surgery. Laryngoscope 103:9599621993

49

Sasaki TTaniguchi MSuzuki IKirino T: En bloc petrosectomy using a Gigli saw for petroclival lesions. Technical note. J Neurosurg 83:5595601995

50

Selesnick SHLiu JCJen ACarew JF: Management options for cerebrospinal fluid leak after vestibular schwannoma surgery and introduction of an innovative treatment. Otol Neurotol 25:5805862004

51

Sen AGreen KMKhan MISaeed SRRamsden RT: Cerebrospinal fluid leak rate after the use of BioGlue in translabyrinthine vestibular schwannoma surgery: a prospective study. Otol Neurotol 27:1021052006

52

Snyderman CHScioscia KCarrau RLWeissman JL: Hydroxyapatite: an alternative method of frontal sinus obliteration. Otolaryngol Clin North Am 34:1791912001

53

Stieglitz LHGiordano MGerganov VRaabe ASamii ASamii M: Petrous bone pneumatization is a risk factor for cerebrospinal fluid fistula following vestibular schwannoma surgery. Neurosurgery 67:2 Suppl Operative5095152010

54

Taguchi YMatsuzawa MSakakibara YSekino H: En bloc mastoidectomy to avoid postoperative retroauricular deformity in the transpetrosal approach. J Clin Neurosci 5:4324331998

55

Tokoro KChiba YMurai MHayashi AKyuma YFujii S: Cosmetic reconstruction after mastoidectomy for the transpetrosal-presigmoid approach: technical note. Neurosurgery 39:1861881996

56

Verret DJDucic YOxford LSmith J: Hydroxyapatite cement in craniofacial reconstruction. Otolaryngol Head Neck Surg 133:8978992005

57

Yuen HWChen JM: Reconstructive options for skull defects following translabyrinthine surgery for vestibular schwannomas. Curr Opin Otolaryngol Head Neck Surg 16:3183242008

58

Zins JEMoreira-Gonzalez APapay FA: Use of calcium-based bone cements in the repair of large, full-thickness cranial defects: a caution. Plast Reconstr Surg 120:133213422007

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