Pseudomeningocele formation following chiari decompression: 19-year retrospective review of predisposing and prognostic factors

Symptomatic Cerebellar Cyst Formation after Foramen Magnum Meningioma Removal: A Case Report

Background  Symptomatic cerebellar cyst formation after surgery is rare and the mechanism remains unknown. We describe a cerebellar cyst that gradually expanded, becoming symptomatic, after the removal of a foramen magnum meningioma and discuss the mechanism of cyst formation. Case Description  A 76-year-old woman with a tumor at the foramen magnum was treated by posterior fossa craniotomy and C1 hemilaminectomy. The patient suddenly developed cerebellar symptoms and consciousness disturbance approximately 1 week into an otherwise good postoperative course. Imaging showed a subcutaneous pseudomeningocele in the occipital region and cerebellar cyst formation. After resolution by fenestration of the cerebellar cyst and duraplasty, the patient's symptoms gradually improved. No tumor or cerebellar cyst recurrence has been detected in over 5 years since the surgery. Conclusion  Postoperative pseudomeningocele appeared crucial for cerebellar cyst formation. Postoperative development of symptomatic cerebellar cysts is rare but should be recognized as a serious, sometimes life-threatening, postoperative complication of posterior fossa surgery.

Chiari Type I Revision Decompressive Surgery Indications and Operative Technique: Experience in a Large Adult Cohort

BACKGROUND

Chiari malformation is characterized by inferior displacement of the cerebellar tonsils through the foramen magnum, frequently resulting in strain related headaches, and motor/sensory dysfunction. Chiari decompression technique varies significantly, possibly contributing to frequent revisions. We reviewed revision Chiari decompressions at our institution to determine the primary indications for revision and outcomes after revision.

METHODS

We retrospectively reviewed patients who underwent revision of Chiari decompression at our institution from 2005 to 2020. Demographics, indications for revision surgery, operative techniques, imaging findings, and preoperative/postoperative symptoms were collected. χ2 test was performed to determine statistical significance using a P < 0.05. Independent predictors of operative outcomes were identified.

RESULTS

A total of 46 patients (91% females, mean age 38.8 years) were included for analysis. The median time to revision surgery was 69.1 months (range 0-364 months) with headache (n = 37, 80%) being the most commonly recurring symptom. Large craniectomy (n = 28, 61%) was the most frequent indication for revision surgery. Thirty-two (70%) patients underwent cranioplasty, 20 (43%) required duraplasty, 15 (33%) required arachnoid dissection, and 15 (33%) required tonsillar reduction during revision surgery. Postrevision follow-up (at 8.9 ± 5.2 months average, range 1-18 months), revealed an average reduction in all Chiari-related symptoms relative to symptoms before the revision.

CONCLUSIONS

The most common indication for revision Chiari decompression was a large craniectomy resulting in cerebellar ptosis. We found that tonsillar reduction paired with modest craniectomy achieved near-complete resolution of symptoms with minimal complications. For patients with recurrent or persistent sequelae of Chiari malformation after decompression, revision may reduce symptom severity.

Successful Management of Iatrogenic Cranial Pseudomeningocele With Subgaleal Shunt

Iatrogenic pseudomeningocele is a common complication of cranial surgeries. However, there are no evidence-based guidelines on how to manage this condition. We report two cases of iatrogenic postoperative cranial pseudomeningocele that failed conservative management including compressive head dressing. Subgaleal shunt placement was utilized with successful resolution in both cases. We postulate that subgaleal shunt placement may be an effective method in the management of iatrogenic subgaleal pseudomeningocele.

Association between synthetic sealants and increased complication rates in posterior fossa decompression with duraplasty for Chiari malformations regardless of graft type

OBJECTIVE

Dural sealants are commonly used in posterior fossa decompression with duraplasty (PFDD) for Chiari malformation type I (CMI). Prior evidence suggests that combining certain sealants with some graft material is associated with an increased rate of complications. In 2018, the authors noted an increased rate of symptomatic pseudomeningocele and aseptic meningitis after PFDD in CMI patients. The authors utilized retrospective and prospective analyses to test the hypothesis that complication rates increase with the use or combination of certain sealants and grafts.

METHODS

The analysis was split into 2 periods. The authors retrospectively reviewed patients who underwent PFDD for CMI at their center between August 12, 2011, and December 31, 2018. The authors then eliminated use of DuraSeal on the basis of the retrospective analysis and prospectively examined complication rates from January 1, 2019, to August 4, 2021. The authors defined a complication as symptomatic pseudomeningocele, bacterial or aseptic meningitis, cerebrospinal fluid leak, subdural hygroma, hydrocephalus, surgical site infection, or wound dehiscence.

RESULTS

From 2011 to 2018, complications occurred in 24.5% of 110 patients. Sealant choice was correlated with complication rates: no sealant (0%), Tisseel (6%), and DuraSeal (15.3%) (p < 0.001). No difference in complication rate was noted on the basis of choice of graft material (p = 0.844). After eliminating DuraSeal, the authors followed 40 patients who underwent PFDD after 2018. The complication rate decreased to 12.5%. All complications after 2018 were associated with Tisseel.

CONCLUSIONS

At the authors' single center, use of sealants in PFDD surgery for CMI, especially DuraSeal, was correlated with a higher complication rate. Eliminating DuraSeal led to a significant decrease in the rate of symptomatic pseudomeningocele and aseptic meningitis.

Management of pseudomeningocele following posterior fossa tumor surgery with absence of hydrocephalus: A case report

Background

The management of pseudomeningocele can be challenging and treatment options vary in the literature. There is currently no algorithm or standard protocol regarding the type and timing of treatment. Until now, there has been a little literature and no case report that used puncture techniques as a conservative treatment. We reported the effectiveness of fluid puncture and pressure dressing as an aggressive nonsurgical management of pseudomeningocele.

Case presentation

A 5-year-old boy with posterior fossa tumor underwent midline suboccipital craniotomy tumor removal and decompression. A week after the surgery, the patient developed buldging in the operation region. Head CT scan showed pseudomeningocele in suboccipital region, a residual calcified tumor was seen, and no enlargement of ventricle. Conservative management was taken and the patient was managed with fluid puncture and pressure dressing. The reduction in size of the pseudomeningocele appeared within 14 days.

Conclusion

Pseudomeningocele is a common complication of posterior fossa surgery. Nonsurgical treatment is the management of choice to reduce the symptoms. Fluid puncture and pressure dressing are effective in reducing symptoms. Surgical intervention is recommended when conservative treatment fails.

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There is currently no standard protocol regarding the type and timing of pseudomeningocele treatment following posterior fossa tumor surgery.

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Nonoperative intervention is preferred for pseudomeningocele without hydrocephalus.

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This case reported that fluid aspiration and pressure dressing are effective in reducing symptoms.

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Surgical intervention should be reserved for failure of conservative treatment

Myofascial Flap Closure Decreases Complications in Complex Surgery of the Craniocervical Junction in Ehlers-Danlos Patients

INTRODUCTION

Patients with Ehlers-Danlos syndrome (EDS) are at elevated risk for soft tissue complications when undergoing decompression with or without fusion of the craniocervical junction. We have previously shown that muscle flap closure can decrease reoperative rates. This study investigated whether myofascial flap closure improved clinical outcomes after simple or complex surgery of the craniocervical junction in EDS patients specifically.

METHODS

We performed a retrospective chart review of EDS patients who had undergone surgery for Chiari malformation at the Weill Cornell Medical Center between 2013 and 2020. Postoperative complications were recorded, including infection, wound dehiscence, seroma, hematoma, hardware removal, cerebrospinal fluid (CSF) leak, reoperation, and pseudomeningocele. Patients were stratified by type of closure and type of surgery. Fisher exact test was used for statistical comparison.

RESULTS

Between 2013 and 2020, 62 EDS patients who had surgery of the cervicocranial junction were reviewed. Of these, 31 patients had complex surgery with myofascial flap closure and 22 had simple surgery with traditional closure. The mean age at the time of surgery was 21.3 years. There were no significant differences in wound complications or reoperation rates between the simple surgery and complex surgery groups. In addition, there were no significant differences in complications between complex surgery with flap closure and simple surgery with traditional closure. Our CSF cutaneous fistula rate was 0%, considerably lower than rates reported in the literature, and, in one case, a patient developed a postoperative pseudomeningocele secondary to a dural leak, but the myofascial flap closure prevented its progression.

CONCLUSIONS

Patients with EDS undergoing surgery of the cervicocranial junction may benefit from myofascial flap closure. Flap closure reduced complications after complex surgery of the craniocervical junction to the level of simple surgery. Our CSF leak rate was exceptionally low and only one patient experienced pseudomeningocele. Myofascial flaps are safe to perform in the EDS cohort and prevented CSF cutaneous fistula formation.

A titanium implant for Chiari malformation Type 1 surgery

Background

Concepts of Chiari malformation Type 1 (CM1) surgery in the present time significantly different. The most common complications are pseudomeningocele (12%) and postoperative CSF leak (5%). The development of pseudomeningocele may be associated with inappropriate restoration of bone and muscles relations.

Methods

The pilot study involved 11 patients aged 24-64 years with a diagnosis of CM1 who had indications for surgical treatment. Special titanium implant enabling fixation of the occipital and cervical muscles at the projections of their normal attachments was developed, it was placed to occipital bone on the final stages of surgical intervention. Surgical technique promoted tightened wound closure neutralizing formation of "dead space" at the place of occipital craniectomy and between muscle layers. The implant was produced by direct metal laser sintering method for each patient individually.

Results

There were no complications during the hospitalization and follow-up period. Postoperative MRI demonstrated adequate formation of the cisterna magna and the absence of pseudomeningocele. During follow-up period there were no signs of pseudomeningocele, CSF leak, surgical scar complications, implant-associated infections, and other complications.

Conclusion

In the study group, no pseudomeningocele cases as long as any other complications associated with surgery had been revealed. The efficacy of the proposed surgical technique using the developed implant should be evaluated in clinical trials with larger patient samples. To simplify preoperative planning and manufacturing of the implant for each patient individually, a set of implants with different specified sizes was developed.

A hospital-based analysis of pseudomeningoceles after elective craniotomy in children: what predicts need for intervention?

OBJECTIVE

In pediatric patients, the development of a postoperative pseudomeningocele after an elective craniotomy is not unusual. Most will resolve with time, but some may require intervention. In this study, the authors analyzed patients who required intervention for a postoperative pseudomeningocele following an elective craniotomy or craniectomy and identified factors associated with the need for intervention.

METHODS

An institutional operative database of elective craniotomies and craniectomies was queried to identify all surgeries associated with development of a postoperative pseudomeningocele from January 1, 2010, to December 31, 2017. Demographic and surgical data were collected, as were details regarding postoperative events and interventions during either the initial admission or upon readmission. A bivariate analysis was performed to compare patients who underwent observation with those who required intervention.

RESULTS

Following 1648 elective craniotomies or craniectomies, 84 (5.1%) clinically significant pseudomeningoceles were identified in 82 unique patients. Of these, 58 (69%) of the pseudomeningoceles were diagnosed during the index admission (8 of which persisted and resulted in readmission), and 26 (31%) were diagnosed upon readmission. Forty-nine patients (59.8% of those with a pseudomeningocele) required one or more interventions, such as lumbar puncture(s), lumbar drain placement, wound exploration, or shunt placement or revision. Only race (p < 0.01) and duraplasty (p = 0.03, OR 3.0) were associated with the need for pseudomeningocele treatment.

CONCLUSIONS

Clinically relevant pseudomeningoceles developed in 5% of patients undergoing an elective craniotomy, with 60% of these pseudomeningoceles needing some form of intervention. The need for intervention was associated with race and whether a duraplasty was performed.

Dural Repair in Cranial Surgery Is Associated with Moderate Rates of Complications with Both Autologous and Nonautologous Dural Substitutes

OBJECTIVE

Duraplasty, a common neurosurgical intervention, involves synthetic or biological graft placement to ensure dural closure. The objective of this study is to advance our understanding of the use of dural substitutes in cranial surgery.

METHODS

The PubMed database was systematically searched to identify studies published over the past decade (2007-2017) that described duraplasty procedures. Clinical data were disaggregated and analyzed for the comparisons of biological versus synthetic grafts.

RESULTS

A total of 462 cases were included in the quantitative synthesis. Overall, the most common indication for duraplasty was tumor resection (53%). Allografts were more frequently used in decompression for Chiari malformations compared with xenografts and synthetic grafts (P < 0.001). Xenografts were more frequently used in decompressive hemicraniectomy procedures for evacuation of acute subdural hematomas over allografts and synthetics (P < 0.001). Synthetic grafts were more frequently used in tumor cases than biological grafts (P = 0.002). The cumulative complication rate for dural substitutes of all types was 11%. There were no significant differences in complication rates among the 3 types of dural substitutes.

CONCLUSIONS

Dural substitutes are commonly used to ensure dural closure in a variety of cranial procedures. This study provides greater insight into duraplasty practices and highlights the moderate complication rate associated with the procedure. Future studies are needed to determine the safety and efficacy of such procedures in larger prospective cohorts.

"Stealth cranioplasty:" A novel endeavor for symptomatic adult Chiari I patients with syringomyelia: Technical note, appraisal, and philosophical considerations

Aim and Objective:

In this article, we describe a novel technique of reconstruction of posterior fossa by cranioplasty with use of preshaped titanium mesh following posterior fossa decompression (PFD) for Chiari malformation type I (CMI) with syringomyelia (SM) in symptomatic adults.

Materials and Methods:

Eleven patients underwent limited PFD and expansive cranioplasty with preshaped titanium mesh, what we term as “Stealth Cranioplasty” (SCP), following arachnoid preserving duraplasty (APD) and hexagonal tenting of the duraplasty with the cranioplasty (HTDC) for the management of symptomatic adult CMI with SM. All these patients had syringes extending from 3 to >10 vertebral levels.

Results:

Seven male and four female symptomatic CMI adult patients, between age ranges of 22 and 44 years (mean 29.45 years), presented with different neurological symptoms related to CMI and SM for 6–84 months (mean 37.09 months). All the patients underwent PFD, APD followed by SCP and HTDC and were followed up for 7–54 months (mean 35.90 months). Of 11 patients, 8 patients improved according to the Chicago Chiari Outcome Scale (CCOS) with score of 13–15 while 3 patients remained unchanged with CCOS of 12, and there was no worsening. There was no complication related to Chiari surgery in any of the patients. All the patients had good reestablishment of cisterna magna. Two patients had marked reduction of syrinx while eight patients had moderate-to-mild reduction and one patient had no change of syrinx. None of the patients needed redo surgery.

Conclusion:

SCP is an effective, fruitful, and cost-effective technique for the management of symptomatic adult CMI with SM. This technique has the advantages of preventing complications and recurrences in addition to the improvement of symptoms by addressing the basic pathology.

Thirty-day outcomes for posterior fossa decompression in children with Chiari type 1 malformation from the US NSQIP-Pediatric database

PURPOSE

The multicenter National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database maintained by the American College of Surgeons was used to describe 30-day outcomes following Chiari type 1 decompression in children and to identify risk factors for readmission, reoperation, and perioperative complications.

METHODS

We identified patients aged 0-18 years who underwent posterior cranial fossa decompression for Chiari type 1 malformation in 2012, 2013, and 2014 in the NSQIP-Pediatric database. Multivariate regression analysis was performed using preoperative and perioperative data to determine risk factors for perioperative adverse events within 30 days of the index procedure.

RESULTS

We identified 1459 patients from the NSQIP-P database for the years 2012-2014. Fifty-five percent of the patients were female. Mean age was 9.8 years (median 10 years). Median operative time was 141 min (IQR 107-181 min). Postoperative complications were noted in 5.3 % and unplanned reoperations in 3.4 % of the patients. Postoperative ventriculoperitoneal shunt placement occurred in 0.9 % of the patients. Wound problems were the most common complication (3.8 % of all patients). Univariate analysis showed the following factors were associated with perioperative adverse events: longer operative times, hospital stay ≥5 days, hydrocephalus, and neurological, renal, and congenital comorbidities. On multivariate analysis, female sex (OR 1.46, 95 % CI 1.01-2.11), increased operative time (OR 1.01, 95 % CI 1.00-1.01), and hospital stay ≥5 days (OR 2.62, 95 % CI 1.55-4.43) were independent factors associated with perioperative adverse events.

CONCLUSION

The NSQIP-P database was used to describe surgical outcomes of posterior cranial fossa decompression in a US nationwide sample of 1459 children with Chiari type 1 malformation. The overall recorded adverse rate was low. Longer operative times and length of hospital stay ≥5 days during the index admission were associated with perioperative adverse events.

Complicated Pseudomeningocele Repair After Chiari Decompression: Case Report and Review of the Literature

BACKGROUND

Pseudomeningocele is a recognised complication after posterior fossa decompression for Chiari malformation. Its management can be challenging and treatment options vary in literature.

CASE DESCRIPTION

A difficult-to-treat case of a pseudomeningocele after posterior fossa decompression for a Chiari I malformation is presented. A 34-year-old woman underwent an initial decompression followed by multiple revision surgeries after the development of a symptomatic pseudomeningocele and a low-grade infection. Complications associated with standard treatment modalities, including lumbar drainage and dural repair, are discussed. A review of the existing literature is presented.

CONCLUSIONS

The reported case ultimately required complete removal of all dural repair materials to eliminate the patient's low-grade infection, a muscular flap, and placement of a ventricular-peritoneal shunt for definitive treatment after a trial of a lumbar drain led to herniation and development of a syrinx.