Use of tissue adhesive in the surgical treatment of cerebrospinal fluid leaks. Experience with isobutyl 2-cyanoacrylate in 12 cases

Transcription

1 Use of tissue adhesive in the surgical treatment of cerebrospinal fluid leaks Experience with isobutyl 2-cyanoacrylate in 12 cases JOHN A. MAXWELL, M.D., AND STEPHEN I. COLDWARE, M.D. Division of Neurological Surgery, Department o1 Surgery, University of Kansas Medical Center, Kansas City, Kansas This report describes 12 cases of cerebrospinal fluid leak repaired with isobutyl 2-cyanoacrylate. We have found this tissue adhesive to be a valuable technical adjunct in the management of this problem and have not seen any general or local toxicity to the material. KEY WORDS tissue adhesive isobutyl 2-cyanoacrylate cerebrospinal fluid otorrhea T HE localization and repair of cerebrospinal fluid (CSF) leaks have long taxed the endurance of the surgeon and the welfare of the patient. Improvements in the radiographic recognition of bone defects, radioisotope demonstration of abnormal egress of CSF, and the recent advent of a tissue adhesive, isobutyl 2-cyanoacrylate (IBC), have facilitated our management of patients with this problem. This report is based on our 5-year experience (March, 1968 to January, 1973) with 12 patients who have had CSF leaks repaired with this tissue adhesive. Clinical Material and Methods Clinical Material Table 1 outlines the histories, operative findings, and follow-up data in 12 cases selected for repair. The adhesive was used in cases in which repair was deemed to be difficult with conventional techniques. The obvious advantages of rapid watertight closure and lack of toxicity soon made us aware, however, that an IBC seal was probably the optimal treatment for all such leaks. In Case 4 (Fig. 1 ), a previous craniotomy had failed to prevent the leak or a subsequent. In Case 7 (Fig. 2), multiple otologic procedures had been unsuccessful in stopping the otorrhea. Technique A routine craniotomy was done with generous intradural exposure. The margin of the defect in the dura was fully exposed and the field dried. Neural structures were walled off with cottonoids. A patch of fascia or pericranium was secured over the hole in 332 J. Neurosurg. / Volume 39 / September, 1973

2 Tissue adhesive for CSF leak FIG. 1. Case 4. Drawing of bone defect involving the tip of the left temporal fossa; the dural defect was similar. Closure with pericranial graft secured required gluing to the dura of the left cavernous sinus. small increments, using an eye dropper to apply the glue. If the fistula was large, it was first packed with macerated muscle dipped in the glue to support the graft. All repairs have been accomplished with pericranial or temporalis fascia grafts except Case 7 in which fascia lata was required to repair the massive defect. The technique of repair has been well illustrated and described by VanderArk, et al? ~ No repairs were performed in the presence of active intracranial infection although pneumocephalus existed in Case 4. The advisability of using the technique for Case 9 was doubtful; because of hydrocephalus and rapid refilling of the nasal meningocele, we felt a prompt, secure, watertight seal as well as valve control of the hydrocephalus was warranted. Discussion We feel tissue adhesive facilitates the technical repair of CSF leaks. It is simple to apply, has a strong and rapid bonding FIG. 2. Case 7. Drawing of the massive defect after the patient was struck in the left temporal area by a shattering grinding wheel. The dural defect approximated the bone defect which involved temporal squama to well above the zygoma and the entire floor of the left middle cranial fossa. Note that the anterior aspect of the petrous apex was missing; this area was the likely source of the persistent otorrhea. action, and only small amounts are required to produce a durable watertight seal. Isobutyl 2-cyanoacrylate (IBC) has been found to be less toxic but is more slowly absorbed than the related acrylate compounds with shorter alkyl side chains2-6,1~ These compounds also have a bacteriostatie action that may help to reduce the possibility of infection. 8 Inflammatory and degenerative changes have been reported. TM However, we were easily able to protect vital structures at operation and noted no local or general toxic effects of the glue. The use of tissue adhesives to repair CSF leaks was pioneered at the Waiter Reed Army Medical Center. 7,'3a~ VanderArk, et al., ~5 reported that 15 Walter Reed cases showed no adverse effects and no recurrence of CSF leak or with a follow-up as long as 4 years. NystrSm 1~ in Finland reported the use of Biobond (a mixture J. Neurosurg. / Volume 39 / September,

3 John A. Maxwell and Stephen I. Goldware TABLE 1 Cases in which isobutyl 2-cyanoacrylate (IBC) was used to seal CSF leaks Case Age, History No. Sex 1 45 F profuse spontaneous CSF after upper respiratory infection 1 mo duration; smell intact 2 55 F spontaneous profuse right nostril for 2 mos after upper respiratory infection; smell intact 3 60 M dura resection after removal of left frontal oligodendroglioma with dural seeding; CSF 4 32 M bullet wound of right maxilla passing through face, destroying tip of left temporal fossa, 2 episodes pneumococcal, left ; skull x-ray showed pneumocephalus filling dilated left ventricular system 5 18 M closed head injury at age 15, intermittent left CSF, 2 episodes 6 8F 7 26 M closed head injury at age 4, 4 episodes pneumococcal, no overt CSF leak, laminograms showed 2 cm defect in right cribriform plate injury by fragment of grinding wheel left temporal area, CSF otorrhea 2 yrs without ; smell intact 8 33 F depressed left frontal fracture in motorcycle accident age 15, continuous left nostril CSF, I0 episodes, organism unknown 9 inf. F I day M hydrocephalic newborn with 3 cm midline globular nasal encephalocele well covered with skin, encephalocele filled promptly with CSF after sterile needle drainage, ventriculoperito~aeal shunt performed before craniotomy for repair of leak closed head injury at age 25 with nasal fracture, 2 yrs later, no F profuse CSF leak for 1 mo following excision of small acoustic neuroma that required grinding away the posterior wall of interior acoustic meatus, smell intact, facial nerve function normal M auto accident 4 yrs before, left delayed 2 yrs, 1 episode 334 J. Neurosurg. / Volume 39 / September, 1973

4 Tissue adhesive for CSF leak TABLE 1 (continued) Operative Operative Follow-up Finding Treatment empty sella turcica with small defect anteriorly 1 cm diam. left cribriform plate defect dural defect communicating with defect in posterior right frontal sinus enlarged left temporal horn communicating through 3 cm defect in tip of left temporal fossa 1 cm diam. bilateral cribriform defect in dura and bone 2 cm right cribriform plate defect with brain hernia massive dural and bone defect involving entire middle cranial fossa and petrous apex (Fig. 2) 2 cm diam. defect of right planum sphenoidale with herniation of chiasmatic cistern into defect stalk of meningocele exiting through 2 paramedian 4 mm holes just anterior to eribriform plate sphenoid unroofed and packed with macerated muscle coated with 1BC; pericranial grafts sealed defect packed with macerated muscle soaked in IBC; temporalis fascia graft bonded over graft pericranial graft coated placed extradurally temporalis fascia graft bonded over defect (Fig. 1) defect plugged with macerated muscle coated, pericranial graft sealed defect plugged with macerated muscle soaked in IBC, temporalis fascia graft sealed withe IBC large fascia lata patch glued to basilar dura and closed with a routine silk suture line superiorly defect filled with macerated muscle soaked in IBC, temporalis fascia graft bonded over defect defect filled with macerated muscle soaked in IBC, pericranial graft bonded 4 yrs; no 3 89 yrs; no no leak; died of tumor 1 yr later recurrent ; operative resealing 2 yrs later 3 yrs; no or 2 yrs; no or 2 yrs; no 15 mos; no leak 8 mos; no leak 5 x 10 cm defect lateral to right olfactory groove leak into the mastoid cells through posterior meatus visualized by total mastoidectomy 21~ x la,5 cm defect of left posteromedial orbit and cribriform plate, lateral spenoid wing crushed but no apparent dural defect defect packed with macerated muscle coated, pericranial graft secured enlarged posterior meatus and mastoid cavity filled with macerated muscle soaked in IBC and a viable muscle and fascia flap defect filled with methyl methacrylate, pericranial graft sealed 8 mos; no leak 7 mos; no CSF leak, facial nerve function preserved 2 mos; no leak J. Neurosurg. / Volume 39 / September,

5 John A. Maxwell and Stephen I. Goldware containing methyl 2-cyanoacrylate) to close four CSF leaks, with one failure. In our 12 cases, we were successfully able to stop the CSF leakage, Case 3 represented the only complication, postoperative ; although the patient was reexplored, we were not able to prove a recurrent leak. Using conventional techniques, Ray and Bergland 14 experienced 27% recurrent leaks following the initial repair (6% of their failures were due to anatomical misdirection of the repair). Ommaya, et al., TM reported five failures in 18 cases of nontraumatic repair. The conservative management of CSF leaks may be complicated by the risk of intracranial infection. 2,9,~ Meningitis had been a preoperative complication in five of our patients; one patient had endured 10 episodes of. Lewin, ~ in 26 unoperated cases of CSF, had six instances of intracranial infection including four fatalities. He therefore advised early surgical repair for all CSF leaks. Other neurosurgeons advise surgical repair in cases of persistent CSF leaks. 1,~ We feel that CSF leaks should be treated conservatively for 2 to 3 weeks prior to surgical repair and that IBC is a safe and valuable technical adjunct in their management. Addendum Since preparation of this report, two additional frontal fossa leaks have been successfully repaired using IBC. Acknowledgments The authors wish to thank Ethicon, Inc., for supplying the isobutyl 2-cyanoacrylate, and Dr. Michael McNally of Colorado Springs, Colorado, for the report on Case 10. References I. Brawley BW, Kelly WA: Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 26:57-61, Brisman R, Hughes JE, Mount LA: Cerebrospinal fluid. Arch Neurol 22: , Healey JE Jr, Gallager HS, Moore EB, et al: Experience with plastic adhesive in the nonsuture repair of body tissues. Am $ Surg 109: , Kline DG, Hayes GJ: An experimental evaluation on the effect of a plastic adhesive, methyl 2-cyanoacrylate, on neural tissue. J Neurosurg 20: , Lehman RAW, Hayes GJ; The toxicity of alkyl 2-cyanoacrylate tissue adhesive: brain and blood vessels. Surgery 61: , Lehman RAW, Hayes GJ, Leonard F: Toxicity of alkyl 2-cyanoacrylates. I. Peripheral nerve. Arch Surg 93: , Lehman RAW, Hayes GJ, Martins AN: The use of adhesive and lyophilized dura in the treatment of cerebrospinal..i Neurosurg 26:92-95, Lehman RAW, West RL, Leonard F: Toxicity of alkyl 2-cyanoacrylates. II. Bacterial growth. AWch Surg 93: , Lewin W: Cerebrospinal fluid in nonmissile head injuries. Clin Neurosurg 12: , Messer HD, McVeety H, Ruskin AP: The effect of application of plastic adhesives to dog brains, in Healey JE (ed): Proceedings of a Symposium on Physiological Adhesives, Houston, Houston, University of Texas, 1966, pp I. Nystr6m SHM: On the use of biobond in the treatment of cerebrospinal and frontobasal fistula. Int Surg 54: , Ommaya AK, Di Chiro G, Baldwin M, et al: Non-traumatic cerebrospinal fluid. J Neurol Neurosurg Psychiat 31: , Pitkethly DT, VanderArk GD, Ducker TB, et al: A tissue adhesive in neurosurgery: experience with isobutyl 2-cyanoacrylate. Med Ann D C 39: , Ray BS, Bergland RM: Cerebrospinal fluid fistula: clinical aspects, techniques of localization, and methods of closure. J Neurosurg 30: , VanderArk GD, Pitkethly DT, Ducker TB, et al: Repair of cerebrospinal fluid fistulas using a tissue adhesive. $. Neurosurg 33: , Woodard SC, Hermann JB, Cameron JL, et al: Histotoxicity of cyanoacrylate tissue adhesive in the rat. Ann Surg 162: , 1965 Address reprint requests to: John A. Maxwell, M.D., Division of Neurological Surgery, Department of Surgery, University of Kansas Medical Center, Rainbow Boulevard at 39th Street, Kansas City, Kansas J. Neurosurg. / Volume 39 / September, 1973