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.
