Human dural replacement with acellular dermis: clinical results and a review of the literature.

BACKGROUND: The search for the ideal dural replacement in the setting where autogenous tissues are unavailable or inadequate still persists. Because of the ability of acellular dermis (AlloDerm, LifeCell Corporation, The Woodlands, TX) to remodel itself into native tissue, this dynamic quality is hypothesized to occur when used as a dural replacement. METHODS: We report the long-term outcome of a small cohort of patients who, to our knowledge, were the first patients to receive AlloDerm for dural replacement. In addition, to put these current findings in a historical perspective, we present a review of the literature for dural replacement. RESULTS: Ten patients all successfully underwent duraplasty with AlloDerm with only one postoperative complication that was not related to the acellular dermal dural repair. CONCLUSIONS: We contend that AlloDerm is a safe and viable option for dural replacement in cases in which autogenous tissues are either unavailable or insufficient for proper reconstruction.

Applications of fast-setting hydroxyapatite cement: cranioplasty.

A variety of autogenous and synthetic materials have been used to repair cranial defects resulting from traumatic and iatrogenic causes. In theory, the ideal material should be readily available and safe. It should adequately protect the underlying central nervous system, resist cerebrospinal fluid fistula formation, and be easily contoured. One promising synthetic biomaterial that has been used for cranioplasty is hydroxyapatite cement. This biomaterial has successfully restored cranial contour in most patients in whom it has been used; however, difficulties have arisen because of the material's prolonged water solubility. When exposed to cerebrospinal fluid or blood, inadequate setting of the cement occurs, resulting in loss of its structural integrity. This problem can be alleviated with the use of fast-setting hydroxyapatite cement, which hardens 6 to 12 times faster than the traditional cement. We present, to the best of our knowledge, the first series of the use of this material in 21 patients requiring cranioplasty. The advantages and limitations of fast-setting hydroxyapatite cement will be discussed.

Vulnerability to calcium-induced neurotoxicity in cultured neurons expressing calretinin.

Calretinin (CR) is a calcium-binding protein purported to have neuroprotective properties. This study was designed to characterize the types of neurons containing CR in two different primary cultures and to determine which, if any, CR-immunoreactive (CR-ir) neurons are resistant to excitotoxic insults. Calretinin-containing neurons in cortical primary cultures derived from E14 rat embryos were not resistant to either kainic acid or a brief calcium overload induced by the calcium ionophore A23187. Equal proportions of CR-ir and GABAergic cortical neurons were lost after a 24-h exposure to 100 or 500 microM kainic acid. A 3 microM, 3-h exposure to A23187 induced equivalent amounts of cell loss in both the total cell and CR-ir cortical neuron culture populations. Cortical cultures grown for 6-7 days were more vulnerable than 12- to 13-day-old cultures to short-term, low-concentration treatments of A23187. Older cultures, however, were more severely affected when examined 24 h after a 3-h exposure to A23187. Calretinin-immunoreactive neurons derived from the diencephalon were relatively more resistant than cortical neurons to kainic acid at 6-7 days in vitro. In cortical or diencephalic cultures, CR was rarely coexpressed with GABA or calbindin D-28k. No vasoactive intestinal peptide, substance P, or parvalbumin was detected in CR-ir neurons in either culture system. We suggest that the presence of CR alone is not sufficient to spare neurons from a toxic calcium overload. Calretinin may still buffer calcium at low concentrations or be a component in a calcium-based signal transduction system.

Use of an acellular dermal allograft for dural replacement: an experimental study.

OBJECTIVE: In this study, a nonimmunogenic, acellular, dermal collagen matrix termed XenoDerm (LifeCell Corp., The Woodlands, TX) was examined for use as a dural replacement material in a porcine model. This model was used to investigate whether AlloDerm (LifeCell), an almost identical material made from human dermis, could be safely used in neurological surgery. METHODS: Bilateral temporoparietal dural defects were surgically created in 12 Yucatan minipigs. One side was repaired with autologous pericranium, and the other was repaired with XenoDerm. The pigs were killed after 1, 3, or 6 months, and the areas of dural repair were collected and examined macroscopically and histologically. XenoDerm is derived from porcine skin collected in thin sheets. It is processed so that the epidermis and all dermal cells are removed without disruption of the collagen matrix, rendering the material immunogenically inert and resistant to calcification. It is packaged as a freeze-dried sheet and is easily rehydrated at the time of surgery. RESULTS: There were no postoperative complications, and all pigs survived. Both grafts performed well as dural replacements in all cases. There was no macroscopic evidence of inflammation or cerebrospinal fluid leakage. The XenoDerm grafts were intact, retained their original dimensions, and resembled the surrounding dura. The autologous pericranial grafts, in contrast, were thicker than when implanted and had bony excrescences firmly adhering to their surfaces. Again, however, there was no evidence of cerebrospinal fluid fistulae. There was no gross adherence to the underlying meninges or brain tissue in any specimen. Repopulation by fibroblasts and neovascularization were evident in the XenoDerm grafts as early as 1 month after surgery; by 3 months, the XenoDerm had been remodeled to assume the connective tissue appearance of the surrounding dura. CONCLUSION: In this porcine model, an allograft of acellular dermis is a nearly ideal dural replacement. AlloDerm, the human equivalent of XenoDerm, would be an allograft of acellular dermis after implantation in human subjects. On the basis of this study and previous work with AlloDerm in other reconstructive applications, it is proposed that this material could be similarly used for duraplasty in human subjects.

Chymotrypsin gene expression in rat peripheral organs.

Prior studies have revealed the presence of chymotrypsinlike protease in peripheral organs, although no definitive evidence for the synthesis of this enzyme in tissue other than the pancreas is available. In an attempt to detect chymotrypsinogen mRNA in peripheral organs, a fragment of the pancreatic chymotrypsin mRNA from rat was amplified using PCR. The sequence was identified as a portion of the rat chymotrypsin B gene overlapping exon 5 through exon 7. It was subcloned into the pGEM-4Z vector and used as a template for the vitro transcription of an antisense riboprobe. Using ribonuclease protection and Northern blot analyses, chymotrypsin mRNA was detected in the rat pancreas, stomach, duodenum, ovary, and spleen. Monoclonal and polyclonal antisera against chymotrypsin detected chymotrypsinlike immunoreactivity in rat and human pancreas, rat stomach, duodenum and jejunum. Electrophoresis and immunoblotting revealed chymotrypsin-chymotrypsinogen bands (25-29 kDa) in the stomach and duodenum. Synthesis of a potent protease such as chymotrypsin in tissue other than pancreas is significant, suggesting a potential physiological and/or pathological role in these tissues.

Calretinin-immunoreactive dopaminergic neurons from embryonic rat mesencephalon are resistant to levodopa-induced neurotoxicity.

Levodopa, which is used in the treatment of Parkinson's disease, has known cytotoxic effects on dopaminergic neurons grown in culture. Calretinin (CR) is a cytosolic calcium-binding protein found in specific subpopulations of neurons as well as in some nonneuronal tissue. CR is expressed in 10% of rat embryo dopaminergic neurons grown in vitro. Since it has been postulated that CR provides neuroprotection due to its calcium-binding properties, we investigated whether CR-containing dopaminergic neurons were spared from levodopa toxicity. Incubation of mesencephalic cells with 10(-5) to 10(-7) M levodopa on Days 1-6 in vitro produced no significant effects on the number of dopaminergic neurons containing CR, but resulted in the loss of approximately 65% of the dopaminergic cells which did not contain CR. The remaining CR-negative dopaminergic neurons exhibited dose-dependent reductions in neurite length. The neuronal processes in CR-containing dopaminergic cells retained a smooth bipolar appearance. CR-immunoreactive cells which did not contain dopamine showed slight neurite length decreases at the highest drug concentrations but no changes in neuron number. These results indicate that CR may protect dopaminergic neurons from levodopa-induced toxicity.