The patient was operated by me 25-June-2014 for CSF leak collecting under the posterior fossa skin pocket and muscle was applied. The patient did fine, but recollection of the pocket took place the second day. It was decided to do revision of the dura to see what is happening.

In prone position, the old incision was refreshed and the bone flap reflected to the neck. The muscle is in place, but the CSF is leaking from the surround. Using 4 zero nylon stitches were used to ad more points of closure from the oozing points. The defect is still oozing. 2 pieces of muscle were harvested from the neck muscles and were stitched over these areas and Glubran was applied aided with nylon stitches to obtain more secure closure. The CSF still oozing from the glue layer. Further 2 pieces of neck muscles were applied to other oozing areas with aid of nylon stitches and Glubran. There is still oozing CSF from the center of the area. A huge piece of fascia lata was harvested from the left leg and 4 big pieces were applied over the dura to obtain hermetic space below the bone flap, which was stitches. Water-tight closure of the wound.

Smooth postoperative recovery. The patient sent to the ward.

The patient the next day showed normal dressing without accumulation of CSF leak. The habit of creating osteoplastic craniotomy in the posterior fossa with reflection of the flap to the neck the last 25 years showed its importance in this case. The flap kept its blood supply and it protected the dura during daily puncturing by needle to evacuate the collected CSF over 2 weeks and helped to hold the muscle harvested from the fascia lata to obtain hermetic sealing of the extradural space to prevent further CSF leak.

It is the first case in my life with over 34 years of neurosurgical activity, having such difficult case. Despite the fact, that the dura was water-tightly closed, but due to previous infection, the CSF leak came from the stitch points and from under the first time harvested muscle.

Glubran was not helping to obtain water-tight closure. The CSF droplets were slipping from under the glue forming bubbles. Further layers of Glubran were also forming bubbles. The only remained solution was to harvest a big piece of muscle from the fascia lata to hermetically seal the extradural space under the bone flap.