Abstract
Background
Meningo-cerebral adhesions are frequently encountered during recurrent high-grade glioma resections. Adhesiolysis not only lengthens operation times, but can also induce focal cortical tissue injury that could affect overall survival.
Methods
Immediately after the primary resection of a high-grade glioma, a polyesterurethane interpositional graft was implanted in the subdural space covering the entire exposed cortex as well as beneath the dural suture line. No postoperative complications were documented. All patients received adjuvant radiotherapy. Upon repeat resection for focal tumor recurrence, the graft was shown to effectively reduce meningo-cerebral adhesion development.
Conclusion
The implantation of a synthetic subdural graft is a safe and effective method for preventing meningo-cerebral adhesions.
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Key Points
1. The subdural space is an iatrogenically created cavity formed upon durotomy.
2. The dural border cell layer is the structurally weakest innermost layer of the dura mater that is cleaved when the dura is reflected.
3. Injury to the dural border cell layer triggers early inflammation with the proliferation and migration of fibroblasts, infiltration of macrophages, and the deposition of collagen into adjacent tissue.
4. Meningo-arachnoid adhesions not only lengthen operation durations, but adhesiolysis can also cause cortical vessel and irreversible parenchymal injury.
5. Implanting a physical barrier between the dural border cell layer and the arachnoid mater can reduce the development of meningo-cerebral adhesions.
6. A synthetic dural substitute comprised of polyesterurethane can be used as a subdural implant to protect exposed eloquent cortex and vital cortical vasculature.
7. The graft should be positioned to cover the entire exposed cortex and placed beneath the dural suture line.
8. Care should be taken to avoid kinking or injuring bridging subdural veins by the graft.
9. Graft anchoring to the overlying dural edge by non-absorbable sutures is recommended to prevent its migration.
10. Watertight closure of the dura over the graft is necessary to reduce the risk of surgical site infection especially in the presence of foreign material.
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Woo, P.Y.M., Ng, O.K.S., Li, R.P.T. et al. Reducing meningo-cerebral adhesions by implanting an interpositional subdural polyesterurethane graft after high-grade glioma resection. Acta Neurochir 164, 2057–2062 (2022). https://doi.org/10.1007/s00701-022-05163-4
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DOI: https://doi.org/10.1007/s00701-022-05163-4