Integrity of dural closure after autologous platelet rich fibrin augmentation: an in vitro study

Autologous platelet-rich fibrin as an alternative epidural patch for persistent post-dural puncture headache: A single-center observational study

ObjectivesEpidural blood patch (EBP) is the current standard of care for postdural puncture headache (PDPH). However, when EBP fails to provide relief, patients may experience discomfort and functional impairments. This study reports the safety and efficacy of a novel approach that uses autologous platelet-rich fibrin (PRF) as an alternative epidural patch.MethodsSixty-seven patients with persistent PDPH symptoms after conservative medical treatment were screened. Among them, 12 (18%) patients underwent multiple EBP (range: 1-6), which failed to resolve the PDPH symptoms. As an alternative method, an epidural PRF patch (EPP) was used, in which PRF was injected percutaneously epidurally under fluoroscopic guidance. Patient symptoms were collected perioperatively, and a follow-up period of up to 6 months was conducted.ResultsThe 12 patients included showed good tolerance for the EPP procedure, with injection volumes ranging from 15 to 39 ml. Compared to EBP, patients reported a significant reduction in injection-associated pain, as measured by the unidimensional numeric rating scale, with a mean reduction of 52.8% (p ≤ 0.05). The headache impact test scores (HIT-6) obtained before and 6 months after EPP revealed a statistically significant reduction in symptoms by a mean of 33.3% (p ≤ 0.05). Moreover, no adverse effects were observed during follow up. It is noteworthy that all patients experienced significant relief from PDPH-associated symptoms 6 months after the intervention.ConclusionEPP may be a viable solution for patients with persistent PDPH symptoms. Notably, the discomfort experienced due to pain during the EPP procedure was markedly less than that experienced during the EBP procedure. The fact that clinical improvement was observed after 6 months is encouraging and lays the groundwork for additional clinical investigations.

Platelet rich fibrin and commercial sealants for dural closure in neurosurgery: An in vitro study

BACKGROUND

Watertight closure of the dura mater is essential after neurosurgical interventions to avoid complications such meningitis, intracranial hypotension and surgical site infections. In addition to conventional suturing techniques, various biomaterials have been proposed as sealants to minimize the risk of leakage. We previously reported that patient derived platelet-rich fibrin (PRF), an autologous biomaterial, significantly improves watertight dural closure when applied as an onlay over a standard running suture. To demonstrate the efficacy of this method, we aimed to compare this orthobiological approach with other commercially available sealants.

METHODS

We utilized an in vitro testing device that allowed for the assessment of watertight dura mater closure via hydrostatic testing. On our testing phantom using freshly harvested bovine dura maters, a standardized 20-mm incision was closed using a running suture, and the leak pressure was measured initially without (primary leak pressure) and subsequently with on lay augmentation (secondary leak pressure) using either PRF, fibrinogen- and thrombin-coated collagen patch (TachoSil®), collagen matrix graft (DuraGen®), Polyethylenglykol (PEG) and polyethylene glycol ester and trilysine amine hydrogel solution (DuraSeal®), polyethylene glycol, protein-reactive polyethylene glycol monomer coated collagen matrix (Hemopatch®) or polyethylenimine component autospray sealant (Adherus®).

RESULTS

The outcomes demonstrate that the usage of a dural onlay in addition to the standard running suture exhibited a substantial improvement in leak pressure compared to the running suture alone. Specifically, the median leak pressure was improved by 3.5 times, where the combined approach was able to withstand 38 cm H2O, whereas the running suture alone had a median leak pressure of 11 cm H2O. Upon evaluating the performance of the sealants, we identified two categories of dural sealants: a medium performance group (30 ± 2 cm H2O) comprised of Adherus® (31 cm H2O), DuraGen® (31 cm H2O), and Hemopatch® (28 cm H2O), and a high-performance group composed of DuraSeal® (45.5 cm H2O), and TachoSil® (41 cm H2O). Patient-derived PRF was able to withstand a max pressure of 45 cm H2O, falling into the high-performance group. Of all the sealants tested in this study, the PRF based patch demonstrated the lowest variance in leak pressure among all the tested sealants.

CONCLUSIONS

Autologous platelet-rich fibrin in a two-step procedure displayed enhanced augmentation and reinforced watertight closure of the dura mater, exhibiting a four-fold increase in leak pressure compared to standard running suture alone. Among other commonly utilized commercial sealants, it ranked second with demonstrated consistency in its performance.

Platelet rich fibrin three-layer reconstruction of the sellar floor after endoscopic endonasal transsphenoidal approach: technical note and initial experience

Background

Cerebrospinal fluid (CSF) leakage frequently complicates endoscopic endonasal transsphenoidal pituitary resections, despite the use of lumbar drains, nasoseptal flaps, or commercial dura sealants. Managing this complication often requires revision surgery and increases the risk of infection. Platelet-rich fibrin (PRF), an affordable autologous biomaterial derived from the patient's blood through short, angulated centrifugation, contains growth factors and leukocytes embedded in a fibrin matrix. PRF exhibits regenerative properties in various surgical disciplines. This study assesses a three-layer sellar reconstruction method employing solid membranous (s-PRF) and high-viscosity injectable (i-PRF) forms of PRF.

Materials and methods

We present our initial experience on a series of 22 patients with pituitary macroadenomas. For all patients, an endoscopic transnasal transsphenoidal approach was selected. Following the resection of the pathology, sellar reconstruction was accomplished using a three-layer orthobiologic technique. A membranous s-PRF was utilized as an inlay inside the opened sellar floor, followed by a layer of injectable i-PRF finally covered with another s-PRF membrane over the top to the sellar corridor.

Results

In all cases the implementation of the proposed three-layer PRF reconstruction strategy was feasible and safe. During the 12-month follow-up period there were no adverse effects reported associated with the PRF application. 77% (17/22) of the patients demonstrated intraoperatively a cerebrospinal fluid (CSF) leak (Esposito Grade 1-3). In total, the proposed PRF reconstruction effectively prevented postoperative CSF leaks in 95% of the patients and in 94% of those with an Esposito Grade 1-3. One of the two patients with intraoperative Esposito Grade 3 developed a CSF leak on the first postoperative day, which was successfully managed with a lumbar drain for 5 days.

Conclusion

Sellar reconstruction after endoscopic endonasal transsphenoidal resection of pituitary adenomas with PRF is feasible and safe. The three layer PRF augmentation is a novel technique to prevent CSF-leakage.

Treatment of a symptomatic cervical cerebrospinal fluid fistula after full endoscopic cervical foraminotomy with CT-guided epidural fibrin patch

BACKGROUND

There is only limited data on the management of cerebrospinal fluid (CSF) fistulas after cervical endoscopic spine surgery. We investigated the current literature for treatment options and present a case of a patient who was treated with CT-guided epidural fibrin patch.

METHODS

We present the case of a 47-year-old female patient with a suspected CSF fistula after endoscopic decompression for C7 foraminal stenosis. She was readmitted 8 days after surgery with dysesthesia in both upper extremities, orthostatic headache and neck pain, which worsened during mobilization. A CSF leak was suspected on spinal magnetic resonance imaging. A computer tomography (CT)-guided epidural blood patch was performed with short-term relief. A second CT-guided epidural fibrin patch was executed and the patient improved thereafter and was discharged at home without sensorimotor deficits or sequelae. We investigated the current literature for complications after endoscopic spine surgery and for treatment of postoperative CSF fistulas.

RESULTS

Although endoscopic and open revision surgery with dura repair were described in previous studies, dural tears in endoscopic surgery are frequently treated conservatively. In our case, the patient was severely impaired by a persistent CSF fistula. We opted for a less invasive treatment and performed a CT-guided fibrin patch which resulted in a complete resolution of patient's symptoms.

DISCUSSION AND CONCLUSION

CSF fistulas after cervical endoscopic spine procedures are rare complications. Conservative treatment or revision surgery are the standard of care. CT-guided epidural fibrin patch was an efficient and less invasive option in our case.

Fat enhanced leukocyte-platelet-rich fibrin versus fascia lata in endoscopic reconstruction of CSF leaks

PURPOSE

The aim of this study was to use a new biological active fat enhanced leukocyte-platelet-rich fibrin membrane (L-PRF) for skull base defect reconstruction and compare its validity and reliability with the time-honored fascia lata.

METHODS

This prospective study was conducted on 48 patients with spontaneous CSF leaks who were divided into 2 matched groups by stratified randomization, 24 patients in each group. In group A we performed multilayer repair using fat enhanced L-PRF membrane. In group B we used fascia lata for the multilayer repair. In both groups we enforced the repair with mucosal grafts/flaps.

RESULTS

The two groups were statistically matched for age, sex, intracranial pressure, and site and size of the skull base defect. There was no statistically significant difference between the two groups regarding the outcome of the repair or recurrence of CSF leak during the first postoperative year. Meningitis occurred in one patient in group B and was successfully treated. Another patient in group B developed thigh hematoma which resolved spontaneously.

CONCLUSION

The fat enhanced L-PRF membrane is a valid reliable option in repair of CSF leaks. The membrane is autologous, readily available, easily prepared, and has the advange of including stromal fat, stromal vascular fraction (SVF), and leukocyte-platelet-rich fibrin (L-PRF). The present study showed that fat enhanced L-PRF membrane is stable, non-absorbable, not liable to shrink or become necrotic, and can establish good seal of the skull base defect and further enhance the healing process. The use of the membrane also has the advantage of avoiding thigh incision and possible hematoma formation.

Leukocyte- and platelet-rich fibrin in endoscopic endonasal skull base reconstruction: study protocol for a multicenter prospective, parallel-group, single-blinded randomized controlled non-inferiority trial

BACKGROUND

Recent advances in endoscopic endonasal transsphenoidal approaches (EETA) for skull base lesions have resulted in a significant increase in extent and complexity of skull base defects, demanding more elaborate and novel reconstruction techniques to prevent cerebrospinal fluid (CSF) leakage and to improve healing. Currently, commercially available fibrin sealants are often used to reinforce the skull base reconstruction. However, problems have been reported regarding hypersensitivity reactions, efficacy, and costs. This trial aims to investigate autologous leukocyte- and platelet-rich fibrin (L-PRF) membranes as an alternative for commercially available fibrin glues in EETA-related skull base reconstruction reinforcement.

METHODS/DESIGN

This multicenter, prospective randomized controlled trial aims to demonstrate non-inferiority of L-PRF membranes compared to commercially available fibrin sealants in EETA cases (1) without intra-operative CSF-leak as dural or sellar floor closure reinforcement and (2) in EETA cases with intra-operative CSF-leak (or very large defects) in which a classic multilayer reconstruction has been made, as an additional sealing. The trial includes patients undergoing EETA in three different centers in Belgium. Patients are randomized in a 1:1 fashion comparing L-PRF with commercially available fibrin sealants. The primary endpoint is postoperative CSF leakage. Secondary endpoints are identification of risk factors for reconstruction failure, assessment of rhinological symptoms, and interference with postoperative imaging. Additionally, a cost-effectiveness analysis is performed.

DISCUSSION

With this trial, we will evaluate the safety and efficacy of L-PRF compared to commercially available fibrin sealants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03910374. Registered on 10 April 2019.

Leukocyte- and platelet-rich fibrin in cranial surgery: study protocol for a prospective, parallel-group, single-blinded randomized controlled non-inferiority trial {1}

BACKGROUND

CSF leakage is a major complication after cranial surgery, thus, adequate dural closure must be performed. Commercially available fibrin sealants are currently considered the gold standard for dural closure, but problems have been reported regarding safety, efficacy, and costs. This trial aims to investigate autologous leukocyte- and platelet-rich fibrin (L-PRF) as an alternative to commercially available fibrin sealants.

METHODS/DESIGN

This single-blinded, prospective randomized controlled interventional trial aims to demonstrate the non-inferiority of L-PRF compared to commercially available fibrin sealants for dural closure. This trial will include patients undergoing cranial neurosurgery (supratentorial and infratentorial) with intentional opening of the dura. Patients are randomized in a 1:1 fashion comparing L-PRF to commercially available fibrin sealants. The primary endpoint is postoperative CSF leakage within 12 weeks after surgery. Secondary endpoints are complications such as bleeding or wound infections. Additionally, a cost-effectiveness analysis is performed.

DISCUSSION

With this trial, we will evaluate the safety and efficiency of L-PRF compared to commercially available fibrin sealants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03812120. Registered on 22 January 2019.

Application of Fibrin Associated with Photobiomodulation as a Promising Strategy to Improve Regeneration in Tissue Engineering: A Systematic Review

Fibrin, derived from proteins involved in blood clotting (fibrinogen and thrombin), is a biopolymer with different applications in the health area since it has hemostasis, biocompatible and three-dimensional physical structure properties, and can be used as scaffolds in tissue regeneration or drug delivery system for cells and/or growth factors. Fibrin alone or together with other biomaterials, has been indicated for use as a biological support to promote the regeneration of stem cells, bone, peripheral nerves, and other injured tissues. In its diversity of forms of application and constitution, there are platelet-rich fibrin (PRF), Leukocyte- and platelet-rich fibrin (L-PRF), fibrin glue or fibrin sealant, and hydrogels. In order to increase fibrin properties, adjuvant therapies can be combined to favor tissue repair, such as photobiomodulation (PBM), by low-level laser therapy (LLLT) or LEDs (Light Emitting Diode). Therefore, this systematic review aimed to evaluate the relationship between PBM and the use of fibrin compounds, referring to the results of previous studies published in PubMed/MEDLINE, Scopus and Web of Science databases. The descriptors "fibrin AND low-level laser therapy" and "fibrin AND photobiomodulation" were used, without restriction on publication time. The bibliographic search found 44 articles in PubMed/MEDLINE, of which 26 were excluded due to duplicity or being outside the eligibility criteria. We also found 40 articles in Web of Science and selected 1 article, 152 articles in Scopus and no article selected, totaling 19 articles for qualitative analysis. The fibrin type most used in combination with PBM was fibrin sealant, mainly heterologous, followed by PRF or L-PRF. In PBM, the gallium-aluminum-arsenide (GaAlAs) laser prevailed, with a wavelength of 830 nm, followed by 810 nm. Among the preclinical studies, the most researched association of fibrin and PBM was the use of fibrin sealants in bone or nerve injuries; in clinical studies, the association of PBM with medication-related treatments osteonecrosis of the jaw (MRONJ). Therefore, there is scientific evidence of the contribution of PBM on fibrin composites, constituting a supporting therapy that acts by stimulating cell activity, angiogenesis, osteoblast activation, axonal growth, anti-inflammatory and anti-edema action, increased collagen synthesis and its maturation, as well as biomolecules.

MANAGEMENT OF RECURRENT CSF LEAK AFTER OCCIPITAL TUMOR SURGERY: A CASE REPORT

We present the case of a 10-year-old male with recurrent CSF leakage after surgery for an occipital tumor. Initial management of the CSF leak, including debridement, re-exploration, and lumbar drain insertion, failed to address the problem. The last resort was the insertion of the EVD, which managed to stop the leak. Cerebrospinal fluid leakage remains one of the most common complications in neurosurgery. CSF leakage can prolong hospitalization, require further surgery, and cause tension pneumocephalus, CSF infection, and wound dehiscence. Management of postoperative cerebrospinal fluid leakage includes suturing the surgical wound and applying pressure dressings or through surgical means such as cerebrospinal fluid diversion and re-exploration.