Titanium mesh-assisted dural tenting for an expansile suboccipital cranioplasty in the treatment of Chiari 1 malformation

Cerebellar ptosis and dural prolapse are known complications after posterior craniocervical decompres- sion of Chiari 1 malformation (CM1), and are associated with larger craniectomies, epidural scarring and intradural adhesions. Although management of these complications has been well documented, little has been reported in regards to their prevention. We describe our variation of the posterior fossa decompres- sion technique for CM1 using a titanium mesh-assisted dural tenting expansile cranioplasty to prevent both cerebellar ptosis and dural prolapse. A watertight dural augmentation patch is performed after posterior craniocervical decompression. A titanium mesh cranioplasty is performed to cover the superior aspect of the craniectomy. The duraplasty is then tented to the titanium mesh plate with several interrupted sutures. The titanium mesh plate was intended to prevent postoperative cerebellar ptosis or sag, while the dural tenting was performed to prevent delayed collapse and restenosis of the cistern magna. Four patients with CM1 underwent this technique without complication. Postoperative MRI did not demonstrate cerebellar ptosis, restenosis or collapse of the cisterna magna. The expansile suboccipital cranioplasty with titanium mesh-assisted dural tenting technique is a simple and efficient strategy that may be useful to prevent cerebellar ptosis and dural prolapse and maintain the patency of the surgically created neo-cisterna magna.