Evaluation of Non-Watertight Dural Reconstruction with Collagen Matrix Onlay Graft in Posterior Fossa Surgery

OBJECTIVE: Many surgeons advocate for watertight dural reconstruction after posterior fossa surgery given the significant risk of cerebrospinal fluid (CSF) leak. Little evidence exists for posterior fossa dural reconstruction utilizing monolayer collagen matrix onlay graft in a non-watertight fashion. Our objective was to report the results of using collagen matrix in a non-watertight fashion for posterior fossa dural reconstruction. METHODS: We conducted a retrospective review of operations performed by the senior author from 2004-2011 identified collagen matrix (DuraGen) use in 84 posterior fossa operations. Wound complications such as CSF leak, infection, pseudomeningocele, and aseptic meningitis were noted. Fisher's exact test was performed to assess risk factor association with specific complications. RESULTS: Incisional CSF leak rate was 8.3% and non-incisional CSF leak rate was 3.6%. Incidence of aseptic meningitis was 7.1% and all cases resolved with steroids alone. Incidence of palpable and symptomatic pseudomeningocele in follow-up was 10.7% and 3.6% respectively. Postoperative infection rate was 4.8%. Previous surgery was associated with pseudomeningocele development (p<0.05). CONCLUSION: When primary dural closure after posterior fossa surgery is undesirable or not feasible, non-watertight dural reconstruction with collagen matrix resulted in incisional CSF leak in 8.3%. Incidence of pseudomeningocele, aseptic meningitis, and wound infection were within acceptable range. Data from this study may be used to compare alternative methods of dural reconstruction in posterior fossa surgery.

Chronic Lymphocytic Inflammation with Pontine Perivascular Enhancement Responsive to Steroids with a Significant Elevation of beta-2 Microglobulin Levels

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a relapsing-remitting disorder for which steroid administration is a key to control the progression. CLIPPERS can exhibit radiological features similar to malignant lymphoma, whose diagnosis is confounded by prior steroid administration. We report a case of CLIPPERS accompanied by abnormal elevation of beta-2 microglobulin in the cerebrospinal fluid (CSF). A 62-year-old man started to experience numbness in all fingers of his left hand one year ago, which gradually extended to his body trunk and legs on both sides. Magnetic resonance imaging demonstrated numerous small enhancing spots scattered in his brain and spinal cord. CSF levels of beta-2 microglobulin were elevated; although this often indicates central nervous system involvement in leukemia and lymphoma, the lesions were diagnosed as CLIPPERS based on the pathological findings from a biopsy specimen. We emphasize the importance of biopsy to differentiate between CLIPPERS and malignant lymphoma because the temporary radiological response to steroid might be the same in both diseases but the treatment strategies regarding the use of steroid are quite different.