Objective: Dural repair in areas with limited operative maneuverability has long been a challenge in cerebral surgery. This is especially true in skull base meningiomas and other dural-based lesions, where aggressive dural resection is often limited by the inability to repair dural defects in confined spaces. Without adequate dural closure, postoperative complications including cerebrospinal fluid leaks and infection can occur. Here, we show a novel method by which nonpenetrating titanium clips can be used to repair dural defects in areas with limited space.
Case Presentation: We present two patients who underwent dural repair with vascular microclips. Both repairs involved difficult-to-reach areas in which primary dural suturing was impractical: one case involved a clinoidal meningioma and the other a recurrent cerebellar hemangiopericytoma extending below the foramen magnum.
Technique: Our method utilizes a clip applier to repair dural defects. The applier contains twenty-five, 3-mm titanium clips that are applied to the dura by squeezing a lever resting under the surgeon’s thumb and forefinger. The clips are rapidly placed in an interrupted fashion, similar to applying skin staples for wound repair. With forceps apposing the edges of the dura and graft material, the clips are inserted circumferentially until completion.
Conclusion: In our experience, intracranial dural closure with nonpenetrating, nonmagnetic, titanium clips is an effective method for dural repair in spaces with limited operative maneuverability.
Fig. 1 (A, B) Pre-operative contrast-enhanced axial and coronal computed tomography (CT) of the brain revealing a homogenously enhancing right cerebellar hyperdensity extending inferiorly to the level of the V3–4 segment of the vertebral artery. Evidence of previous craniotomy is demonstrated by the presence of embolic material present in the occipital artery feeders. (C) Postoperative contrast enhanced axial CT of the brain revealing the outline of the clips around the affixing the dural patch to the native dura. Gross total resection was achieved. Artifact is visible from the embolization materials. Images windowed for viewing both the brain and the bone reveal no clip artifact. (D) Intraoperative picture demonstrated successful primary dural repair with clips. The embolized vertebral artery and C1 are labeled for reference.Fig. 2 (A) Pre-operative contrasted enhanced T1-weighted axial and coronal images revealing a dural-based lesion stemming from the right anterior clinoidal process with associated extensive boney overgrowth. (B) Postoperative contrasted enhanced T1-weighted axial and coronal images revealing resection of the enhancing portion of the tumor not extending into the cavernous sinus. Note the hyperostosis has been drilled away. (C, D) Intraoperative view from a right-sided minipterional approach. The optic nerve is visibly unroofed and involved dura overlying the clinoid and orbital roof has been resected. (E-J) The dural graft material has been placed at the edge of the remaining dural edge overlying the optic nerve which is visible in the background. Forceps are used to grasp the dural edge and the graft material while the clips are applied in succession. The graft is clipped in place circumferentially until a complete closure is achieved.
