Childs Nerv Syst (2009) 25:183–190
DOI 10.1007/s00381-008-0700-y
ORIGINAL PAPER
Suboccipital decompression for Chiari I malformation:
outcome comparison of duraplasty with expanded
polytetrafluoroethylene dural substitute versus
pericranial autograft
Frank J. Attenello & Matthew J. McGirt &
Giannina L. Garcés-Ambrossi & Kaisorn L. Chaichana &
Benjamin Carson & George I. Jallo
Received: 10 April 2008 / Revised: 14 June 2008 / Published online: 4 September 2008
# Springer-Verlag 2008
Abstract
Objective Treatment failure for Chiari decompression is
frequently associated with scarring, intradural adhesions,
and recurrent loss of hindbrain space. While autograft has
been our standard for hindbrain duraplasty, we investigated
whether introducing anti-adhesive synthetic GORE PRE-
CLUDE® MVP® Dura Substitute (expanded polytetrafluoro-
ethylene [ePTFE] graft) was associated with improved
patient outcomes.
Materials and methods We retrospectively reviewed
records of patients undergoing first-time suboccipital
decompression/duraplasty for Chiari-I malformation utiliz-
ing ePTFE graft or pericranial autograft. Magnetic reso-
nance imaging (MRI) at last follow-up was assessed for: (1)
recurrent loss of dorsal hindbrain cerebrospinal fluid (CSF)
space/CSF flow(cine-MR) at duraplasty site, (2) pseudo-
meningocele, or (3) syringomyelia improvement. Symptom
recurrence warranting revision surgery was compared
between cohorts.
Results Sixty-seven patients (age11±5 years) underwent
duraplasty with pericranial autograft (n=40) or ePTFE graft
(n=27). Perioperative morbidity did not differ between
cohorts. No patients receiving ePTFE graft experienced
incisional CSF leak, surgical site infection, or symptomatic
F. J. Attenello : M. J. McGirt : G. L. Garcés-Ambrossi :
K. L. Chaichana : B. Carson : G. I. Jallo
Department of Neurosurgery, Johns Hopkins School of Medicine,
Baltimore, MD, USA
G. I. Jallo (*)
600 North Wolfe St.,
Baltimore, MD 21287, USA
e-mail: gjallo1@jhmi.edu
pseudomeningocele. At median 8 months postoperatively,
all (100%) patients with ePTFE graft maintained physio-
logical CSF flow/decompressed hindbrain CSF space on
cine-MRI versus 32 (79%) patients receiving pericranial
autograft (p< 0.05). Radiographic syrinx improvement
occurred in 80% of patients with ePTFE graft and 52% of
patients with pericranial autograft (median time to improve-
ment: 5 vs 12 months, respectively, p<0.05). At median
16 months postoperatively, four (10%) patients with
pericranial autograft required revision decompression versus
0 (0%) patients with ePTFE graft (p=0.090).
Conclusion Duraplasty utilizing ePTFE graft was associated
with improved maintenance of hindbrain space, accelerated
syringomyelia improvement, and a trend toward decreased
treatment failure versus pericranial autograft. Future studies
of long-term outcome are warranted to confirm observed
effects. Synthetic ePTFE graft is a safe alternative for
duraplasty in the setting of Chiari malformation.
Keywords Chiari malformation . Duraplasty . Pericranium .
Gore-tex . ePTFE
Introduction
Hans Chiari first described Type I Chiari malformation over
one century ago as caudal displacement of the cerebellar
tonsils through the foramen magnum [5]. This relatively
common pathology has now been associated with multiple
symptoms of the cerebellum, brainstem, and spinal cord
[30, 44, 46]. The definitive treatment for Chiari I malfor-
mation has remained posterior fossa decompression, com-
monly involving posterior fossa craniectomy, laminectomy,
184
and duraplasty [2, 10, 28]. However, as many as one third
of patients may experience symptom recurrence when
followed years after surgery [3, 4, 7, 8, 23, 35, 37, 38,
42, 43]. Reoperation for treatment failure often reveals the
source of symptom recurrence to be scarring and intradural
adhesions at the site of decompression [1, 9, 25, 29, 41].
This scarring is often associated with recurrent loss of
hindbrain space and obstruction of cerebrospinal fluid
(CSF) flow on cine flow imaging [27].
For posterior fossa decompression requiring duraplasty, a
synthetic dural substitute, expanded polytetrafluoroethylene
(ePTFE) (GORE PRECLUDE® MVP® Dura Substitute),
theoretically provides a brain-interface surface with micro-
scopically smooth barrier that minimizes neural tissue
attachments, as well as an outer surface textured for
biological fixation and sealing, potentially promoting para-
spinal muscle adhesion and graft tenting away from
hindbrain. Having introduced this synthetic dural graft into
our practice several years ago, we now retrospectively assess
its efficacy in the surgical treatment of Chiari I malformation.
Materials and methods
In order to assess the outcomes associated with duraplasty for
pediatric Chiari I malformation utilizing pericranium auto-
graft versus synthetic ePTFE dural patching (GORE PRE-
CLUDE® MVP® Dura Substitute, W.L. Gore & Associates,
Inc.), we retrospectively reviewed the records of all patients
surgically treated by two pediatric neurosurgeons at our
institution over a 10-year period. Only patients undergoing
first-time suboccipital decompression and duraplasty for
Chiari I malformation were included in the review. Patients
with achondroplasia, ventral brainstem compression (basilar
invagination or platybasia), cranio-facial or other skeletal
syndromes were not included.
Presenting symptomatology, neurological deficits, de-
mographics, co-morbidities, pre- and postoperative radio-
logical studies, operative records, and follow-up clinical
records were reviewed in 67 consecutive cases. An
electronic database was recorded by cataloging patient
demographics, presenting symptoms, and degree of tonsil
herniation. Additionally, the presence of syringomyelia,
scoliosis, and hydrocephalus were also identified from
preoperative magnetic resonance images (MRIs) and
recorded. All patients in this series were offered surgical
decompression if they presented with symptoms consistent
with Chiari I malformation (tussive headache, cervical
pain, central apnea, dysphagia, aspiration, vertigo, vocal
cord paralysis, motor/sensory deficits, nystagmus, ataxia,
uncoordination, and syringomyelia) and demonstrated
cerebellar tonsil herniation at least 5 mm below the
foramen magnum.
Childs Nerv Syst (2009) 25:183–190
Surgical technique
The surgical technique for craniectomy and duraplasty was
standardized for all patients treated by the two surgeons.
Both surgeons applied the same surgical approach and
technique to Chiari I patients. All patients underwent surgery
in the prone position with the head fixed in a Mayfield or a
horseshoe head holder. A small suboccipital craniectomy
and a C-1 laminectomy were performed. The craniectomy
usually extended from the foramen magnum upward,
including the inferior nuchal line of the occipital bone,
covering the insertion area of the rectus capitis posterior
minor muscle, and the medial insertion area of the rectus
capitis posterior major muscle. This typically measured 3 cm
in width and 3 cm in height for both surgeons. Both surgeons
ensured an adequate decompression of the rim of the
foramen. For duraplasty, the dura was opened in a Y-shaped
fashion spanning the majority of the 3×3 cm craniectomy. In
order to ensure the reconstruction of open CSF space at the
craniospinal junction, an expansile duraplasty was per-
formed using either a pericranial autograft or a synthetic
ePTFE graft (GORE PRECLUDE® MVP® Dura Substitute).
Cerebellar tonsils were not coagulated in any of the cases
reviewed in this series. The only variation in surgical
technique between surgeons was the material used for
hindbrain duraplasty. The decision to utilize pericranium
autograft or ePTFE graft was entirely based on the surgeon’s
preference and unrelated to patient characteristics. All cases
performed by surgeon 1 utilized pericranium autograft. All
cases performed by surgeon 2 utilized synthetic ePTFE graft.
For both surgeons, a watertight dural closure was performed
using 4.0 neurolon suture in all cases. All dural grafts were
sutured with a running stitch. Once the graft was stitched,
several valsalva maneuvers were induced to check for CSF
leak. If CSF egress was noted during valsalva, additional
stitches were placed. At conclusion of grafting, fibrin glue
was applied to the edges of the graft. Paraspinous muscle
was re-approximated tightly and the skin closed with a
running absorbable 4.0 Caprosyn stitch.
Radiographic outcome assessment
Patients routinely underwent an MRI evaluation 3 months
and 1 year after surgery to assess hindbrain decompression.
For the purposes of this study, two radiographic endpoints
were assessed from postoperative MRIs of all patients: (1)
loss of dorsal hindbrain CSF space or CSF flow at the
duraplasty site, or (2) presence of pseudomeningocele.
Postoperative axial T2-weighted MRIs were reviewed to
determine if the decompressed dorsal hindbrain CSF space
was maintained at the cervicomedullary junction (at the site
of duraplasty); Fig. 1c. Postoperative phase-contrast cine
MRI studies were also reviewed to determine whether
Childs Nerv Syst (2009) 25:183–190
Fig. 1 A representative example of a phase-contrast cine MR, b
sagittal T1-weighted MR, and c axial T2-weighted MR at the level of
the cervicomedullary junction obtained 8 months after duraplasty in a
patient receiving synthetic ePTFE graft (left) or pericranial autograft
(right). a Physiologic CSF flow is demonstrated by arrowheads with
in patient with ePTFE graft but is absent in patient with pericranial
autograft. b Sagittal MR demonstrates maintenance of dorsal
hindbrain CSF space and ePTFE graft adherence to paraspinal muscle
but not brain pia (arrows). Loss of dorsal hindbrain CSF space is
demonstrated with pericranial graft (arrows). c Axial MR demonstrat-
ing ePTFE graft with a V-shaped, expansile duraplasty (arrows) with
CSF dorsal to the cervicomedullary brainstem (arrowheads). Loss of
this expansile duraplasty (arrows) is demonstrated with pericranial
graft 8 months after surgery. Loss of dorsal CSF space or flow (as
demonstrated here) occurred less frequently with ePTFE graft versus
pericranial autograft (0% vs 21%, p<0.05)
dorsal hindbrain CSF flow demonstrated normal bi-phasic
systolic flow or was obstructed at the cervicomedullary
junction (at the site of duraplasty) [17, 27]; Fig. 1a. The
presence of a pseudomeningocele on postoperative MRI
was also recorded.
For patients with Chiari-associated syrinx, postoperative
MRI of the hindbrain and relevant spinal cord was obtained
185
between 3 and 6 months after surgery. MRI was repeated
between 9 and 12 months in patients demonstrating no
improvement in syrinx on their 3- to 6-month postoperative
MRI. Improvement in syrinx was defined as a decrease in
syrinx diameter on axial T2-weighted MRI.
Clinical outcome assessment
The incidence of two clinical outcome events were
recorded: (1) mild to moderate symptom recurrence not
warranting revision surgery and (2) marked symptom
recurrence with loss of decompressed hindbrain space
warranting revision surgery. Patients’ response to surgery
was first assessed at their 3-month follow-up visit to clinic.
Patients were then assessed at 6 and 12 months postoper-
atively. Patients with any persistence of Chiari-related
symptoms were also reassessed 18–24 months after surgery.
If patients continued to demonstrate their preoperative
symptoms consistent with Chiari malformation to any
degree on consecutive follow-up visits, they were recorded
as symptom recurrence. Symptomatology that was not
considered to be related to Chiari malformation or
associated with other identifiable factors was not consid-
ered symptom recurrence. If symptoms persisted or
recurred to a level of severity thought to be equivalent to
the patient’s preoperative level, and MRI suggested
continued or recurrent hindbrain crowding, revision de-
compression was offered.
Statistical analysis
Parametric data was expressed as mean ± standard
deviation and compared via the Student’s t test. Non-
parametric data was expressed as median (interquartile
range) and compared via the Mann–Whitney–Wilcoxon
test. Percentages were compared via the Chi-squared test.
Time to radiographic syrinx improvement was expressed
via the Kaplan–Meier method [21] and compared between
duraplasty cohorts via the Log-rank analysis.
Results
Patient population
Sixty-seven pediatric patients underwent first-time hindbrain
decompression with duraplasty for Chiari I malformation.
Pericranial autograft was utilized for duraplasty in 40 (60%)
cases. A synthetic ePTFE graft (GORE PRECLUDE®
MVP® dural substitute) was utilized for duraplasty in 27
(40%) cases. Mean age was 11±5 years. Sixty-one (91%)
patients presented with tonsillar ectopia between C1 and C2
lamina. Six (9%) patients presented with tonsillar ectopia
186 Childs Nerv Syst (2009) 25:183–190

caudal to C2. Syringomyelia and scoliosis were present in 31
(46%) and 19 (28%) cases, respectively. Headache was the
most common presenting symptom (57% of cases). Patient
characteristics did not significantly differ between treatment
cohorts; Table 1.
Perioperative outcome
No patients receiving ePTFE graft experienced surgical site
infection, incisional CSF leak, or symptomatic pseudome-
ningocele. One patient with ePTFE graft experienced
symptoms attributed to aseptic meningitis. The incidence
of perioperative complications did not differ between
patients receiving ePTFE versus pericranial dural grafts;
Table 2. Median (interquartile range [IQR]) length of
hospitalization was 4 (3–5) days and did not differ as a
function of dural repair.
Radiographic outcome
Sixty-two (93%) patients were available for postoperative
MRI evaluation of the cervicomedullary junction. Patients
were radiographically followed for a median of 8 (4–14)
months after surgery. Length of follow-up did not differ
between cohorts; Table 2. Asymptomatic pseudomeningo-
cele was present in six (24%) patients with ePTFE graft
versus four (11%) patients with pericranial autograft;
Table 2. Pericranial autograft was associated with a higher
incidence of recurrent dorsal hindbrain pathology on MRI
(loss of CSF space or flow) (eight [21%] vs zero [0%], p<
0.05); Table 2, Fig. 1. All patients receiving an ePTFE graft
continued to maintain physiological hindbrain CSF flow
and an adequately decompressed dorsal hindbrain CSF
space on T2 MR imaging; Table 2, Fig. 1. In the pericranial
autograft cohort, dorsal hindbrain CSF flow was obstructed
in five (13.5%) cases and dorsal hindbrain CSF space was
lost at the level of duraplasty in three (8%) cases, a median
of ten [6–14] months after surgery.
For the 31 patients presenting with Chiari-associated
syringomyelia, 19 (61%) demonstrated radiographic im-
provement by a median of 8 (4–14) months after surgery.
Radiographic syrinx improvement was noted in eight (80%)
patients with ePTFE graft versus 11 (52%) with pericranial
autograft; Table 2. Time to syrinx improvement was
significantly less in patients receiving ePTFE graft versus
pericranial autograft (p<0.05); Fig. 2.
Clinical outcome
Patients were clinically followed for a median of 16 [6–24]
months after surgery. The length of follow-up did not differ
between cohorts; Table 2. Mild to moderate symptom
recurrence was noted in 11 (27%) patients with pericranial
autograft versus 3 (11%) with an ePTFE graft (p=0.105).
Four (10%) patients with pericranial autograft required
revision decompression versus zero (0%) patients with an
ePTFE graft (p=0.090); Table 2.
Discussion
In our surgical experience with Chiari I malformation, the
use of a synthetic ePTFE graft has resulted in maintenance
of hindbrain decompression in all cases with zero incidence
of revision decompression. We also have experienced no
cases of surgical site infection, incisional CSF leak, or
symptomatic pseudomeningocele when utilizing ePTFE
dural grafts. Asymptomatic pseudomeningocele occurred

Table 1 Clinical and radio-

graphic presentation of Variable All Pts ePTFE Pericranium
pediatric patients with Chiari I (n=67) (n=27) (n=40)
malformation undergoing
suboccipital decompression, Mean Age (yrs) 11±5 12±5 10±4
C1 laminectomy, and Male 26 (39%) 7 (26%) 19 (48%)
duraplasty with either Ectopia between C1–C2 61 (91%) 24 (89%) 37 (92%)
pericranium autograft versus Ectopia caudal to C2 6 (9%) 3 (11%) 3 (8%)
ePTFE synthetic patch Syrinx 31 (46%) 10 (37%) 21 (52%)
Scoliosis 19 (28%) 6 (22%) 13 (32%)
Duration of S × s (months)a 12 (6–24) 12 (5–24) 12 (6–23)
Primary Symptom
Headache 38 (57%) 17 (63%) 21 (52%)
Syrinx sensory Sx 13 (19%) 5 (18%) 8 (20%)
Syrinx motor Sx 2 (3%) 0 (0%) 2 (5%)
Dyspahagia 5 (7%) 1 (4%) 4 (10%)
Cranial Nerve Dysfunction 4 (6%) 2 (7%) 2 (5%)
Nausea/vomiting 3 (4%) 1 (4%) 2 (5%)
a
Values given as median Apnea 2 (3%) 1 (4%) 1 (2.5%)
(interquartile range)
Childs Nerv Syst (2009) 25:183–190 187

Table 2 Comparisons of perioperative, radiographic, and clinical outcome in pediatric patients with Chiari I malformation undergoing first-time
suboccipital decompression, C1 laminectomy, and duraplasty with pericranium autograft versus ePTFE synthetic patch

Variable All Pts (n=67) ePTFE (n=27) Pericranium (n=40) P value

Perioperative outcome
SSI/Bacterial meningitis 0 (0%) 0 (0%) 0 (0%)
Incisional CSF leak 2 (3%) 0 (0%) 2 (5%)
Aseptic meningitis 2 (3%) 1 (4%) 1 (3%)
Symptomatic pseudomeningocele 1 (1%) 0 (0%) 1 (2%)
Cumulative events 5 (7%) 1 (4%) 4 (10%) 0.336
Radiographic Outcome
Available for MRI follow-up 62 (93%) 25 (93%) 37 (92%)
Months from surgery to MRIa 8 (4–14) 8 (4–12) 10 (6–14)
Radiographic pseudomeningocele 10 (17%) 6 (24%) 4 (11%) 0.169
Loss of dorsal hindbrain CSF space or flowb 8 (13%) 0 (0%) 8 (21%) 0.013
Syrinx Improvementc 19 (61%) 8 (80%) 11 (52%) 0.140
Clinical Outcome
Clinical follow-up (months)a 16 (6–24) 14 (6–17) 16 (6–28)
Symptom recurrence 14 (21%) 3 (11%) 11 (27%) 0.105
Revision hindbrain decompression 4 (6%) 0 (0%) 4 (10%) 0.090
Postoperative months to revisiona 7 (6–11) – 7 (6–11) –
a
Values given as median (range)
b
Loss of hindbrain CSF space dorsal to tonsils on axial T2 MRI or recurrent obstruction of dorsal hindbrain CSF flow on phase-contrast MR
cine-flow study
c
Thirty-one patients presented with Chiari-associated syrinx, improvement defined as sustained reduction in syrinx diameter on axial T2 MRI by
last follow-up

in a larger percentage of patients receiving ePTFE versus
pericranial autograft (24% vs 11%); however, this differ-
ence was not significant. Furthermore, while the absolute
incidence of syrinx improvement did not differ between
graft types, we observed a shorter time to syrinx improve-
ment as well as a decreased incidence of recurrent
radiographic hindbrain pathology with the ePTFE dural
Fig. 2 Incidence of radiographic syrinx improvement as a function of
time after hindbrain decompression and duraplasty displayed via the
estimated Kaplan–Meier method. Patients undergoing duraplasty with
synthetic ePTFE graft versus pericranium autograft demonstrated a
more rapid onset of radiographic syrinx improvement (p<0.05, Log-
rank analysis). Radiographic improvement defined as a sustained
decrease in syrinx diameter on axial T2-weighted MRI
substitute. Both pericranial autograft and ePTFE dural graft
yielded adequate outcomes in treatment of this complex
disease.
In our series, the perioperative morbidity of both the
ePTFE and autograft cohorts were comparable to perioper-
ative outcomes reported in literature. Other series of
duraplasty for Chiari I malformation report infection rates
between 0% and 13% [14, 18, 24, 32, 33], meningitis
between 0% and 10% [15, 18, 32, 33, 47], and CSF leak in
0% to 12% [22, 32, 33, 47]. To date, no dural graft has
yielded superior perioperative results. Among 32 patients
receiving duraplasty with pericranial autograft reported by
Fischer and Vanaclocha, none experienced wound infec-
tion, pseudomeningocele, CSF leak, or need for revision
decompression [6, 12, 45]. It is important to note that
pericranial autograft in children can be quite thin and
fragile and leakage unavoidable. Among 74 patients
undergoing duraplasty with xenogeneic pericardium
reported by Parizek and Fillipi, one patient developed a
CSF leak, and no patients experienced wound infection,
pseudomeningocele, or reoperation [6, 11, 34].
Danish et al. recently reported outcomes in 56 patients
receiving duraplasty with a synthetic collagen graft,
DuraGen®. In this series, two patients developed wound
infection, five pseudomeningocele, one CSF leak, and four
required reoperation [6]. Acellular human dermis was also
reported in 45 patients, resulting in one wound infection,
five cases of pseudomeningocele, one CSF leak, and two
188
cases requiring repeat decompression [6]. Despite the good
outcome reported after hindbrain decompression and
duraplasty with various graft types, many surgeons contin-
ue to perform hindbrain dural openings without grafting
with long-term success. Furthermore, many surgeons also
achieve long-term success performing suboccipital decom-
pression without opening the hindbrain dura, highlighting
the fact that duraplasty and dural grafting are not always
necessary when treating this complex disease.
In our series, when compared to pericranium autograft,
synthetic ePTFE graft showed significantly lower inci-
dence of recurrent dorsal hindbrain pathology (CSF flow
obstruction and loss of dorsal hindbrain CSF space). In
addition, among patients with concurrent Chiari-associated
syringomyelia, those receiving ePTFE graft showed a
statistically significant earlier time to improvement. This
result is not unexpected, as physiologic CSF flow was
noted postoperatively in all patients receiving synthetic
ePTFE graft. Past series have demonstrated that restoring
CSF flow plays a large role in the resolution of
syringomyelia [26, 27]. Nevertheless, the absolute inci-
dence of syrinx improvement did not differ between dural
graft types, and it remains unclear whether this difference in
time to improvement carries clinical importance. While
prospective studies are needed to confirm our observations,
the anti-adhesive surface of the ePTFE membrane at the
graft-pia interface may have contributed to maintenance of
CSF flow and rapid improvement of syringomyelia
observed here.
The expanded ePTFE membrane has been successfully
used for many years to prevent tissue adhesion in multiple
tissue interfaces, including cardiac, vascular, and plastic
surgery, where multiple long-term clinical studies have
verified success [16, 20, 31, 39, 40]. The low porosity and
dense interlinking fibers of this ePTFE surgical membrane
are reported to minimize cell in-growth and attenuate
adhesion formation [36].Animal studies have shown that
when both spinal dura and arachnoid mater is excised,
collagen-coated Vicryl mesh and spinal dural allograft
resulted in thick membranes bound to neural tissue, while
ePTFE membranes induced a thin membranous adhesion
[36]. Rabbit studies have also shown a decreased biological
reaction to ePTFE versus lyophilized dura [13]. Clinical
studies utilizing this synthetic membrane for tethered cord
syndrome demonstrated no cases of adhesion of spinal cord
to operative site [19].
In a prospective clinical study of patients undergoing
cranial or spinal surgery requiring duraplasty, 103 patients
were imaged postoperatively, with the vast majority
showing no adhesions (84%) or minimal adhesions (7%)
[29]. Nevertheless, suturing ePTFE grafts with 4.0 neuro-
lon, as we have done, leaves the graft with oversized holes
at the suture site. ePTFE tailored suture is generally
Childs Nerv Syst (2009) 25:183–190
recommended to avoid CSF leakage around suture sites
within the graft. Nevertheless, symptomatic pseudomenin-
gocele was not a problem in any of our cases of ePTFE
despite using 4.0 neurolon.
Though we have highlighted our initial positive experi-
ences utilizing an ePTFE synthetic graft, our conclusions
are limited by the retrospective design of our study. In
addition, all ePTFE grafts were only utilized by a single
surgeon in our study. Therefore, inter-surgeon differences
and their potential biases cannot be accounted for when
comparing the outcomes associated wit these two graft
types. Furthermore, because we do not have long-term
follow-up, late onset pseudomeningoceles or hindbrain
fibrous scarring occurring beyond 2 years postoperatively
cannot be assessed in this study. When symptomatic
hindbrain scarring occurs after Chiari I decompressions, it
tends to occur several years after surgery, beyond the
follow-up period included here.
Prospective and blinded comparative studies assessing
5-year outcomes are warranted to adequately compare
long-term complication between these graft type. Our
sample size remains limited, and future studies will need
to incorporate larger patient groups as use of this
synthetic graft becomes more prevalent. Nevertheless,
we demonstrate in our initial experience that Chiari I
malformation can be successfully treated with duraplasty
utilizing a ePTFE synthetic graft, resulting in minimal
perioperative complications, early improvement in syrin-
gomyelia, and effective maintenance of CSF flow and
hindbrain space.
Conclusions
In our experience with pediatric Chiari malformation,
duraplasty utilizing an anti-adhesive synthetic ePTFE
dural substitute was associated with improved mainte-
nance of hindbrain space, accelerated improvement in
syringomyelia, and a trend toward decreased treatment
failure compared to pericranial autograft. Both pericranial
autograft and ePTFE graft resulted in a low incidence of
perioperative complications and are effective treatment
alternatives. Further studies utilizing larger patient vol-
umes and multiple surgeons are necessary to confirm
these observations. GORE PRECLUDE® MVP® Dura
Substitute is an effective alternative for posterior fossa
decompression with duraplasty in the treatment of Chiari
I malformation.
Acknowledgments This work was funded in part by the American
Syringomyelia Alliance Project Monkton Institute CNS Fellowship
Disclosures Matthew McGirt is a consultant for W.L. Gore &
Associates, Inc.
Childs Nerv Syst (2009) 25:183–190
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