bluuebunny/crossref_metadata_2025_split huggingface dataset:
Management of incisional cerebrospinal fluid leak in open cranial surgeries and the "folding technique" in duraplasty
Authors: Bayatli Eyup , Ozgural Onur , Erdin Engin , Karadagoglu Ümit , Kahilogullari Gokmen , Ugur Hasan Caglar , Tuna Hakan , Attar Ayhan , Unlu Agahan , Caglar Y. Sukru , Dogan Ihsan 
Published: February 2025

OBJECTIVE
The aim of this study was to review a series of patients who underwent open cranial surgeries to evaluate the incidence of iatrogenic incisional CSF leaks and discuss its prevention and management. The authors also discuss the utility of the "folding technique" used in duraplasty as an alternative to conventional dural reconstruction techniques.

METHODS
All patients undergoing open cranial surgery were reviewed, and those with incisional CSF leak were included in this study. CSF leakage was managed using either conservative nonsurgical methods or surgical interventions. When the conservative nonsurgical methods failed to curb the leak, surgical procedures such as lumbar external drainage (LED) using lumbar subarachnoid drainage, external ventricular drainage (EVD), a lumboperitoneal or ventriculoperitoneal shunt (VPS), and reexploration of the surgical site were considered.

RESULTS
Between 2019 and 2024, 2149 patients underwent open cranial surgeries at our hospital for any cranial pathology; 39 (1.8%) of these patients experienced postoperative incisional CSF leakage. The majority of the pathologies requiring surgeries were located in the supratentorial region (76.9%). Patients were classified according to the type of dural closure technique used. Primary stitching, the patient’s fascia, or synthetic dura (resorbable, nonresorbable, or both) were used for dural reconstruction. The median interval between the surgery and the start of the leakage was 19 (IQR 1–79) days in patients with no history of radiotherapy; however, this duration was longer in patients who received radiotherapy (median 45 [IQR 10–540] days). The surgical interventions for CSF leakage were classified as wound resuturing (combined with other conservative approaches such as tightened dressing and elevating the head end of the bed), LED or EVD, or surgical reexploration. The folding technique in duraplasty is a simple way to achieve watertight duraplasty even with autograft or synthetic material.

CONCLUSIONS
Incisional CSF leakage is a potentially preventable complication with high morbidity. Such cases could be managed via conservative approaches including wound resuturing, LED or EVD, and surgical reexploration. However, the management strategy is beyond any strict algorithm. This folding technique for duraplasty is a worthy replacement for conventional primary suturing for dural repair or reconstruction in cranial and even spinal defects. This study highlights the importance of regaining the watertight nature of the dura in the primary surgery to prevent any further intervention and lower the overall morbidity.
Dural and cranial reconstruction techniques in retrosigmoid craniotomy: key factors associated with CSF leaks in 225 patients
Authors: Auricchio Anna Maria , Martinelli Renata , Offi Martina , Nichelatti Michele , Valeri Federico , Rapisarda Alessandro , Di Domenico Michele , Montano Nicola , Olivi Alessandro , Della Pepa Giuseppe Maria 
Published: February 2025

OBJECTIVE
This study evaluated the effectiveness of various dural closure and bone reconstruction techniques in preventing CSF leakage following retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors. The goal was to identify whether newer combinations of reconstructive materials offer any advantage in reducing CSF leaks and improving surgical outcomes.

METHODS
The authors conducted a retrospective review of 225 patients who underwent a retrosigmoid craniotomy for CPA neoplasms between January 2018 and August 2024. Patient demographics, intraoperative reports, and postoperative complications were analyzed. Various reconstructive methods, including the use of TachoSil, HydroSet, autologous or heterologous dural patches, and bone flap repositioning, were compared. CSF-related complications such as CSF leakage, infections, and postoperative hydrocephalus were systematically evaluated.

RESULTS
CSF leakage occurred in 31% of cases (n = 69), while CSF infections and postoperative hydrocephalus were noted in 6% and 7% of patients, respectively. HydroSet combined with bone flap repositioning significantly reduced CSF leakage (p = 0.008), as did the combination of HydroSet and heterologous dural patches (p = 0.007). TachoSil did not show a significant reduction in CSF leakage. Craniectomy with titanium mesh or heterologous cranioplasty was not associated with any CSF leaks. No other single or combined techniques showed significant associations with CSF leakage.

CONCLUSIONS
HydroSet in combination with bone reconstruction and heterologous patches demonstrated superior outcomes in reducing CSF leaks. TachoSil did not significantly affect leakage rates, with less definite results. Refining surgical techniques and selecting appropriate materials for dural and bone reconstruction may help reduce complications and improve patient outcomes in CPA tumor surgeries using the retrosigmoid approach.
Recent experience with calcium phosphate cement cranioplasty after lateral supraorbital keyhole approach to the anterior cranial fossa
Authors: Joncas Colby T. , Lee Veronica , Tugend Margaret , Chance Rachel , McKhann Guy M. , Sekula Raymond F. 
Published: February 2025

OBJECTIVE
Through an eyebrow incision, the lateral supraorbital (LSO) keyhole approach provides access to various lesions in the anterior cranial fossa and affords many of the advantages of minimal access and minimally invasive surgery. The LSO approach and other minimal access approaches including various endonasal approaches to the anterior cranial fossa, however, have been associated with nonnegligible rates of CSF leaks postoperatively. The authors report their recent experience using calcium phosphate cement cranioplasty as a method of preventing CSF leakage after LSO keyhole craniectomy.

METHODS
A retrospective medical records review was performed for 9 consecutive patients undergoing operations by the senior authors using the LSO keyhole approach with skull defect repair using calcium phosphate cement cranioplasty alone between 2022 and 2024. Review of the medical records included clinic notes, imaging studies, and operative notes as well as details regarding the length of hospital stay, complications, and rate of tumor recurrence.

RESULTS
Eight of 9 patients underwent resection of meningiomas, while 1 underwent resection of a cavernous malformation. The cohort consisted of 7 females (78%) and 2 males (22%) with a mean age of 55.2 years. The mean tumor volume among the 8 meningiomas was 18.09 cm3, and peritumoral edema was present in 8 of the 9 cases (89%). Gross-total resection was achieved in 7 of 8 meningioma cases (87.5%). Among the 9 patients, the mean length of hospital stay was 2.4 days. Two patients (22%) experienced complications. No patients experienced a CSF leak postoperatively. At a mean follow-up of 13.8 months, 1 patient (12.5%) experienced tumor recurrence.

CONCLUSIONS
Based on this and prior experience, the use of calcium phosphate cement cranioplasty alone following an LSO keyhole approach to the anterior cranial fossa is a safe alternative to traditional closure techniques, which rely on replacement of bone flap with plates and screws, and it might reduce the rate of postoperative CSF leakage. Larger studies are required to confirm these findings.
Trends in Medicare procedural and reimbursement rates for spinal CSF leak repair (2000–2021)
Authors: Jalal Muhammad I. , Singh Rohin , Santangelo Gabrielle , Schick Alex , Singh Aman , Furst Taylor , Stone Jonathan J. , Vates G. Edward , Paul David A. 
Published: February 2025

OBJECTIVE
CSF leaks are a common complication of spinal surgery, occurring in 3%–16% of elective cases and up to 12% of operatively managed traumatic spinal injuries. They can also occur following lumbar puncture. However, there are limited data on utilization and reimbursement trends within Medicare for CSF leak repairs. Characterizing the economic burden and market of spinal CSF leak repair has implications for optimizing effective management strategies. This study evaluates reimbursement and utilization trends for both surgical repair and epidural blood patch (EBP) management of spinal CSF leaks between the years 2000 and 2021.

METHODS
The 2000–2021 provider utilization and payment files from the Centers for Medicare & Medicaid Services was queried to identify all spinal CSF leak repair procedures billed to Medicare part B. For each management strategy, the number of procedures, total charges submitted by providers, and total Medicare reimbursements were extracted. Monetary data were adjusted to 2021 US dollars using changes to the Consumer Price Index. Spearman rank correlation coefficients were used to analyze trends in reimbursement and utilization.

RESULTS
From 2000 to 2021, 62,826 open surgical repairs were reported with $37,082,407 paid in reimbursement (45.9% repaired without additional laminectomy, 28.8% with laminectomy, and 25.3% requiring a spinal dural graft). An additional 63,227 EBPs were reported for CSF leak repair with $7,567,776 in reimbursement. Reimbursement for CSF leak repair without laminectomy totaled $15,707,094; repairs with laminectomy, $12,429,690; and use of spinal dural grafts, $8,945,444. Both a significant 162% increase in the utilization of spinal dural grafts (333 to 872, p < 0.001) and a decrease in reimbursement ($671 to $496, p = 0.02) was observed from 2000 to 2021. There was a significant 31% decrease in reimbursement for EBP ($148 to $102, p < 0.001).

CONCLUSIONS
Significant variability exists in the management strategy and rates of utilization and reimbursement for treating spinal durotomy. Despite increasing utilization of spinal dural grafts, reimbursement has declined between the years 2000 and 2021. Further studies are required to optimize both the cost effectiveness and efficacy of spinal durotomy repair techniques.
Fibrin-coated collagen fleece "sandwich" closure technique for cranial and spinal dural reconstruction and closure
Authors: Kramer Dallas E. , Kaye Brandon , Sandoval-Consuegra Jose , Jeong Seung W. , Woodhouse Cody , Yu Alexander 
Published: February 2025

OBJECTIVE
Persistent CSF leakage and symptomatic pseudomeningocele formation are a primary concern following intradural posterior fossa and spinal surgeries, with rates approaching 23.7% and 10%, respectively. These complications occur at a higher rate in cases in which a watertight primary closure cannot be attained. In such cases, various dural substitutes and sealants are at the surgeon’s disposal and often require suturing a dural substitute to the existing dura. Herein, the authors describe a novel sutureless inlay-onlay fibrin-coated collagen fleece (TachoSil) "sandwich" closure technique for dural reconstruction and closure.

METHODS
The authors retrospectively reviewed posterior fossa and intradural spinal cases performed by the senior author from January 1, 2021, to August 30, 2024, which used the described novel closure technique when primary closure without expansion could not be attained. Primary outcomes were rates of postoperative CSF leakage, symptomatic pseudomeningocele formation, CSF diversion, infection, and revision surgery.

RESULTS
A total of 13 patients (8 craniotomies, 2 craniectomies, and 3 spinal cases) were identified with a mean age of 61.3 ± 14.0 years. Surgical indications included intra-axial and extra-axial tumors, acute cerebellar infarcts, an unruptured aneurysm, and a ruptured arteriovenous malformation. One patient (7.7%) who underwent emergency craniectomy for acute cerebellar infarct developed a postoperative CSF leak and symptomatic pseudomeningocele with suspicion of pseudotumor cerebri, ultimately requiring CSF diversion. There were no complications among patients receiving craniotomy or intradural spinal surgery. No postoperative infections or revision surgeries occurred.

CONCLUSIONS
The TachoSil sandwich technique represents an effective means of cranial and spinal dural reconstruction and closure in cases in which watertight primary dural closure cannot be achieved.
Management of a large pseudomeningocele and cerebrospinal fluid fistula after microsurgical resection of recurrent lipomyelomeningocele in children
Authors: Etter Manina M. , Greuter Ladina , Guzman Raphael , Soleman Jehuda , Licci Maria 
Published: February 2025

OBJECTIVE
Symptomatic retethering in pediatric patients following complex spinal dysraphism surgery for lipomyelomeningocele (LMMC) repair occurs in approximately 20% of cases. Common complications after repeat surgery for retethering include infection, pseudomeningocele (PMC), and cerebrospinal fluid (CSF) fistula. The authors of this report aim to describe the treatment options for large PMCs or CSF fistulas in a series of patients who underwent repeat surgery for recurrent LMMC at their institution. Additionally, they review management strategies from the literature.

METHODS
This retrospective, descriptive case series includes patients with LMMC who required revision surgery for postoperative PMC or CSF fistula after recurrent untethering procedures at the authors’ institution between 2013 and 2023. The surgical strategies for managing PMC and CSF fistula were examined. References for the narrative literature review were sourced from the PubMed and MEDLINE databases.

RESULTS
Eight patients underwent surgery for recurrent retethering due to worsening neurological deficits, including 2 (25.0%) patients who had undergone multiple previous untethering surgeries. The mean duration between symptom onset and repeat surgery was 11.30 ± 5.50 months. Of these 8 cases, 3 (37.5%) developed large postoperative PMCs and CSF fistulas. These patients required a mean of 4.7 ± 2.9 revision surgeries (range 3–8). Management often involved multiple techniques, including local wound revision, dural repair or sealing, mechanical coverage, tissue reconstruction, and external or internal fluid diversion. In all cases, PMCs and CSF fistulas were successfully treated, and at the final follow-up, all patients had stable neurological conditions compared to their preoperative status.

CONCLUSIONS
Managing symptomatic retethering after LMMC repair is challenging, often complicated by PMC and CSF fistulas due to missing normal anatomical tissue layers, large defects, and poor dorsal support. Successful treatment typically requires a combination of techniques to address CSF-related issues. In the authors’ experience, a multifaceted approach and familiarity with these methods are essential for achieving optimal outcomes.
Modified graded skull base reconstruction for intraoperative CSF leak repair in endoscopic endonasal surgeries: a single-surgeon experience in initial years of practice and nuances in the early learning curve
Authors: Khaleghi Mehdi , Shahid Adnan Hussain , Suggala Sudhir , Dyess Garrett , Hummel Ursula Noelle , Chason Danielle N. , Butler Danner , Thakur Jai Deep 
Published: February 2025

OBJECTIVE
The purpose of this study was to evaluate the outcome of a modified graded reconstruction technique based on the size of intraoperative CSF leaks in patients undergoing endoscopic endonasal surgery performed by a single surgeon in the early years of his practice.

METHODS
The database of patients who underwent endoscopic endonasal approaches (EEAs) between September 2020 and August 2024 was included. Surgical complexity was categorized into levels II, III, and IV. Intraoperative CSF leak was categorized into 4 grades (0–3). Patients were divided into 2 timeline groups (those undergoing an EEA between 2020 and 2022 [group A] and between 2023 and 2024 [group B]) to assess the trends in surgical complexity and repair outcomes.

RESULTS
A total of 69 patients with a mean age of 56 ± 16.9 years (range 12–83 years) were identified; 34 (49.3%) were female. The median body mass index was 31 (> 25 in 82.6%). The most common pathology was nonsecretory macroadenoma (57.9%). The EEA at complexity levels II, III, and IV was performed in 36.2%, 46.4%, and 17.4% of the patients, respectively. Intraoperative CSF leaks grades 1, 2, and 3 were encountered in 39.1%, 7.2%, and 17.4% of the patients, whereas 36.2% did not develop leaks (grade 0). Fat grafts and collagen matrix were used for all patients with grades 1–3. Patients with complexity level II only developed grade 1 and 2 leaks, and none of level III developed grade 3. A nasoseptal flap was used in 4 patients (5.8%), with all having level IV surgery and grade 3 intraoperative leak. Only 1 patient (1.4%) developed a postoperative CSF leak, and a lumbar drain was only used for this patient (1.4%) at the revision surgery. The rate of grades 2 and 3 leaks in group B was significantly lower than in group A (8.3% vs 33.3%, p = 0.022). Temporary nasal packing usage was also significantly lower in group B (8.3%) than in group A (28.9%) (p = 0.049), whereas high-complexity EEA rates and pedicled flap usage were not correlated with the year of surgery.

CONCLUSIONS
A graded endoscopic endonasal repair protocol, combined with the judicious use of lumbar drains and nasoseptal flaps rather than a reflexive approach, helps in minimizing postoperative CSF leak rates. Cross-training of neurosurgery graduates focusing on skull base practice is highly recommended for maximizing good outcomes in their early years of practice. With growing experience, intraoperative leak rates tend to decrease, and the reconstruction relies on a tailored multilayer strategy rather than bulky synthetic materials.
Clinical and radiological presentation of cavernomas according to the Zabramski classification
Authors: Saari Emilia , Koivisto Timo , Rauramaa Tuomas , Frösen Juhana 
Published: February 2025

OBJECTIVE
Cerebral cavernous malformations (CCMs) are a cluster of abnormal vessels of the brain. CCMs have a low risk for intracerebral hemorrhage and appear increasingly often as incidental findings on MRI. Zabramski classification has been used to describe the radiological features of CCMs. How the Zabramski classification associates with the clinical symptoms at presentation and clinical course of the disease is not well established.

METHODS
The authors reviewed the medical records of conservatively managed and surgically treated CCM patients over a 20-year period treated in Kuopio and Tampere University Hospitals. Both clinical and radiological data were analyzed. The modified Rankin Scale (mRS) was used to score the symptoms.

RESULTS
Altogether, 775 CCM patients were identified. In both cohorts, most patients were asymptomatic (53% in the Kuopio University Hospital [KUH] cohort and 64% in the Tampere University Hospital [TAUH] cohort). Most CCMs were located supratentorially (77%, 661/858), and most patients presented with epileptic seizures. Of the infratentorial CCMs, most were located in the cerebellum (61%, 121/198). The most common symptoms caused by these CCMs were double vision, sensory deficits, and impaired balance. The median mRS score for symptoms in all CCMs was 0, and if only symptomatic CCMs were accounted for, it was 2. Most CCMs were Zabramski type II, and these CCMs were relatively asymptomatic, similar to Zabramski type III CCMs. Zabramski type I CCMs were mostly symptomatic, whereas Zabramski type IV CCMs were completely asymptomatic. Of patients with type I CCMs, approximately 15% developed new symptoms within 1 year, and in the long-term follow-up 26% had new symptoms. In radiological follow-up, 81% of the type I CCMs regressed to type II or III. Of type II or III CCMs, 2.3% changed over time to type I. Age was associated with the Zabramski classification (p < 0.001 in the TAUH cohort and p = 0.034 in the KUH cohort).

CONCLUSIONS
Most CCMs are asymptomatic, incidental findings, in particular, nearly all Zabramski type IV CCMs. If symptoms are present, they are mainly associated with Zabramski type I CCMs and occasionally with Zabramski type II or III CCMs. Although most Zabramski type I CCMs will regress to type II or III and remain asymptomatic, over long-term follow-up, up to one-quarter develop new symptoms.
Prognostic factors for long-term outcomes of bilateral pallidal deep brain stimulation in the treatment of Meige syndrome
Authors: Zheng Wentao , Hao Qingpei , Chen Xi , Liu Yezu , Zhang Zihao , Li Zhangyu , Mao Jianyao , Zhou Liwei , Chen Sifang , Tan Guowei , Liu Ruen 
Published: February 2025

OBJECTIVE
This study aimed to investigate the effects of bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) on both motor and nonmotor symptoms in patients with Meige syndrome and to further explore prognostic factors for postoperative outcomes based on the long-term follow-up results.

METHODS
The authors retrospectively reviewed the medical records of a consecutive cohort of patients with refractory Meige syndrome who underwent GPi-DBS at their center from January 2016 to October 2023. Motor function, quality of life, neuropsychological status, and emotional state were assessed using standardized scales at baseline and every 3–6 months thereafter. Univariate and multivariate linear regression analyses were performed to identify independent risk factors affecting long-term motor function after GPi-DBS in patients with steady-state (stable) Meige syndrome.

RESULTS
Fifty steady-state patients were ultimately included and assessed, with a mean follow-up duration of 62.9 ± 24.8 months. At the final postoperative evaluation, Burke-Fahn-Marsden Dystonia Rating Scale movement and disability scores showed improvements of 69% (p < 0.001) and 61% (p < 0.001), respectively. A significant improvement from baseline was observed in postoperative scores on the 36-item Short-Form General Health Survey. Throughout continuous neurostimulation, global cognitive function, neuropsychological status, and mood remained stable. Multivariate linear regression analysis revealed that longer disease duration (standardized β-coefficient −0.375, 95% CI −0.033 to −0.011; p < 0.001) and reduced volume of activated tissue within the sensorimotor subregion of the GPi (standardized β-coefficient 0.597, 95% CI 0.002–0.003; p < 0.001) were independently associated with worse long-term motor performance.

CONCLUSIONS
Bilateral GPi-DBS is an effective, safe, and promising treatment option for intractable Meige syndrome and provides sustained benefits in motor function and quality of life without inducing cognitive or mood-related side effects. Early intervention and accurate electrode placement in the sensorimotor subregion of the GPi are essential for optimizing long-term therapeutic outcomes.