Evaluating Platelet Rich Fibrin and Commercial Sealants for Neurosurgical Dural Closure: An in Vitro Study

Introduction: Ensuring a watertight dura mater seal is crucial to avoid complications. Although conventional suturing is standard, synthetic biomaterials are often used as onlays to reduce cerebrospinal fluid leakage. A previous study showed that using patient-derived platelet-rich fibrin (PRF) on a standard continuous suture significantly improves dura closure. We compared this orthobiological method with other commercial sealants to assess its effectiveness.

Methods: We employed an in vitro testing apparatus that facilitated the evaluation of watertight dura mater closure through hydrostatic testing. On our testing phantom utilizing freshly harvested bovine dura maters, a standardized 20-mm incision was closed using a running suture, and the leak pressure was measured initially without (primary leak pressure) and subsequently with onlay augmentation (secondary leak pressure) using either PRF, fibrinogen- and thrombin-coated collagen patch (TachoSil®), collagen matrix graft (DuraGen®), Polyethylene glycol (PEG) and polyethylene glycol ester and trilysine amine hydrogel solution (DuraSeal®), polyethylene glycol, protein-reactive polyethylene glycol monomer coated collagen matrix (Hemopatch®) or polyethylenimine component autospray sealant (Adherus®).

Results: The results indicate that incorporating a dural onlay alongside the conventional running suture significantly enhanced leak pressure compared to using the running suture by itself. The median leak pressure increased by 3.5 times, with the combined method withstanding 38cm H2O, while the running suture alone managed only 11cm H2O. Analysis of sealant effectiveness revealed two distinct groups: a medium-performance category consisting of Adherus® (31cm H2O), DuraGen® (31cm H2O), and Hemopatch® (28cm H2O), and a high-performance category including DuraSeal® (45.5cm H2O) and TachoSil® (41 cmH2O). Patient-derived PRF, capable of enduring a maximum pressure of 45cm H2O, fell within the high-performance group. Among all tested sealants in this study, the PRF-based patch exhibited the least variation in leak pressure.

Conclusion : A two-stage process utilizing autologous platelet-rich fibrin demonstrated strengthened watertight sealing of the dura mater, showing a quadruple increase in leak pressure when compared to conventional running suture alone. It was classified in the high-performance category among other frequently utilized commercial sealants, demonstrating consistent performance.