Fibrin glue has been used for various surgical procedures including cardiac and abdominal surgery. Fibrin glue augments hemostasis, seals tissues, and may prevent adhesions. The main action of fibrin glue is to enhance wound healing by increasing fibrous mesh, and it is completely bioabsorbable. Animal research suggests that fibrin glue may decrease epidural scar formation. Fibrin glue has been widely used in open neurosurgical procedures and may be effective as an ancillary method in preventing postoperative extradural fluid leakage after dural closures. Percutaneous injection of fibrin glue under CT guidance has been successfully performed in the treatment of dural leaks after spinal surgery28,29 or CSF leaks after suboccipital craniectomy or transphenoidal surgery.30
The combination of fibrinogen and thrombin leads to the formation of a fibrin clot. Fibrinogen is present in cryoprecipitate, which is present in fresh frozen plasma or can be harvest from autologous blood. As long as 5 days may be needed to complete the harvesting of cryo-precipitate from autologous blood, although a more rapid technique has been described. At some centers, the technique can be performed in as little as 5 hours.31 Commercial fibrin glue has been available in Europe for years; approval for limited applications by the U.S. Food and Drug Administration (FDA) came in 1998. Fibrin glue is FDA-approved for cardiopulmonary bypass surgery, trauma surgery for repair of splenic injuries, and colostomy closure. Tisseel (Baxter) and Hemaseel (Haemacure) are the only FDA-approved fibrin sealants, and neither is specifically approved for application in the neuroaxis. However, the product has been widely used for dural closure during open surgical procedures of the brain, spine, and head and neck32 in the United States and in other countries.
The drawback of using cryoprecipitate is that its fibrinogen concentration may vary. Also, preparation of autologous cryoprecipitate may take several days, particularly when the cryoprecipitate has to be processed at an outside facility such as through the Red Cross. Preparation of autologous cryoprecipitate may cost up to $400 per unit. Cryoprecipitate from a nonautologous donor is more readily available for immediate use but does not go through a viral inactivitation process as thorough as that of the commercial version. The commercial product includes several manufacturing steps designed to significantly reduce the risk of viral transmission. In addition, all donors for commercial glue are thoroughly prescreened, and donor plasma is held for up to 3 months until retesting rules out the possibility of an interval seroconversion. The manufacturing process used for the commercial products is more rigorous than that used at most blood bank facilities in preparation of nonautologous cryoprecipitate. The disadvantage of the commercial product is the higher cost if a large amount of fibrin glue is needed.
Both blood-banked cryoprecipitate and the commercial fibrin glue have been administered percutaneously for treatment of postoperative dural tears and for treatment of PDPS and SIH. Fibrin glue has been reported in a single case report to be successful in treating SIH that was unresponsive to two epidural blood patches.33 Fibrin glue patch is a reasonable alternative for patients who cannot have an epidural blood patch. The fibrin patch may be used in patients with CSF hypo-volemia who have concurrent HIV infection, leukemia, severe anemia, or lack of venous access. A fibrin glue patch can also be considered in patients who have persistent CSF hypovolemia symptoms despite epidural blood patching. Fibrin glue has greater adhesive strength than a blood patch, and there is no risk of injecting blood into the sub-arachnoid space. Fibrin glue is probably a better treatment for post-surgical dural tears than EBP.
Transient fever and headache after fibrin patch were described in one patient and may be indicative of aseptic meningitis.28,29 The fibrin patch is a potential medium for infection, but addition of antibiotics to the glue may inhibit clot formation or decrease tensile strength. Allergic reaction to bovine thrombin or bovine aprotinin is possible. The patient should be informed that he or she will be receiving a blood product. Some hospitals may have a separate consent form for patients who are about to receive blood products. There is a rare potential risk of viral transmission, although this has not been reported in connection with fibrin glue patches.
Prophylactic fibrin glue injection for prevention of CSF leak has been studied in an animal and an in vitro model, but there are no published human studies.
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