Novel Use of Fish-Derived Acellular Dermal Matrix for Dural Reconstruction Following Subdural Empyema
Poster #: 036
Session/Time: A
Author:
Adam Nasser Akari, BS, MS
Mentor:
Ramon DeJesus, MD
Research Type: Case Report
Abstract
INTRODUCTION:
Subdural empyema is a rare, but life-threatening intracranial infection with an incidence of 0.1 cases per 100,000 person-years and a mortality rate of 12.2%. Surgical drainage is essential, with craniotomy achieving lower recurrence than burr hole drainage. Following debridement of the dura and scalp, coverage and a neodura are required to prevent cerebrospinal fluid (CSF) leak and worsened infection. Autologous options are limited by donor morbidity, whereas synthetic non-dissolvable products cannot be used in contaminated fields. Kerecis™ is an acellular dermal matrix (ADM) made from wild Atlantic cod skin that contains antimicrobial properties and completely integrates, which may reduce the risk of infection recurrence.
CASE INFORMATION:
A 51-year-old male with insulin-dependent diabetes (HgbA1c 15) was transferred to our level one trauma center with right hemiparesis after one week of antibiotics for a 4 × 4 cm necrotic scalp lesion. Imaging revealed a left subdural empyema with calvarial osteomyelitis. He underwent serial drainage of the empyema, debridement of scalp, pericranial tissue, and osteomyelitic bone, with initial dural repair using Surgicel™, Tisseel™, and DuraGen™. Cultures grew Staphylococcus spp., Lactobacillus spp., and Candida glabrata. Despite these measures, infection progressed, requiring excision of 200 cm² of scalp and 3 × 1.5 cm of nonviable dura. Definitive reconstruction was performed with Kerecis™ ADM for dural closure and a 7.5 × 30 cm free anterolateral thigh flap for scalp coverage using the superficial temporal vessels. The patient recovered without CSF leak or wound complications and was discharged with improved strength and ambulation.
DISCUSSION/CLINICAL FINDINGS:
This case highlights the need for surgical debridement and reconstruction when antibiotic therapy fails. Craniotomy remains the preferred approach for subdural empyema given higher clearance than burr hole drainage. Biologic substitutes such as Kerecis™ offer advantages over synthetic materials in contaminated fields. The extracellular matrix of Kerecis™ provides a scaffold that supports cellular adhesion, neovascularization, and fibroblast proliferation. In animal models, fish collagen scaffolds have demonstrated successful dural repair with prevention of adhesions, minimal inflammation, and effective CSF leak prevention. These properties suggest that Kerecis™ may promote rapid integration and neodura formation, consistent with the favorable outcome in this patient.
CONCLUSION:
This case demonstrates the novel use of fish-derived ADM for dural repair in a contaminated intracranial wound. Kerecis™ ADM may represent a valuable option for achieving neodura formation. Further research is needed to assess its safety, durability, and broader applicability in neurosurgical reconstruction.
Subdural empyema is a rare, but life-threatening intracranial infection with an incidence of 0.1 cases per 100,000 person-years and a mortality rate of 12.2%. Surgical drainage is essential, with craniotomy achieving lower recurrence than burr hole drainage. Following debridement of the dura and scalp, coverage and a neodura are required to prevent cerebrospinal fluid (CSF) leak and worsened infection. Autologous options are limited by donor morbidity, whereas synthetic non-dissolvable products cannot be used in contaminated fields. Kerecis™ is an acellular dermal matrix (ADM) made from wild Atlantic cod skin that contains antimicrobial properties and completely integrates, which may reduce the risk of infection recurrence.
CASE INFORMATION:
A 51-year-old male with insulin-dependent diabetes (HgbA1c 15) was transferred to our level one trauma center with right hemiparesis after one week of antibiotics for a 4 × 4 cm necrotic scalp lesion. Imaging revealed a left subdural empyema with calvarial osteomyelitis. He underwent serial drainage of the empyema, debridement of scalp, pericranial tissue, and osteomyelitic bone, with initial dural repair using Surgicel™, Tisseel™, and DuraGen™. Cultures grew Staphylococcus spp., Lactobacillus spp., and Candida glabrata. Despite these measures, infection progressed, requiring excision of 200 cm² of scalp and 3 × 1.5 cm of nonviable dura. Definitive reconstruction was performed with Kerecis™ ADM for dural closure and a 7.5 × 30 cm free anterolateral thigh flap for scalp coverage using the superficial temporal vessels. The patient recovered without CSF leak or wound complications and was discharged with improved strength and ambulation.
DISCUSSION/CLINICAL FINDINGS:
This case highlights the need for surgical debridement and reconstruction when antibiotic therapy fails. Craniotomy remains the preferred approach for subdural empyema given higher clearance than burr hole drainage. Biologic substitutes such as Kerecis™ offer advantages over synthetic materials in contaminated fields. The extracellular matrix of Kerecis™ provides a scaffold that supports cellular adhesion, neovascularization, and fibroblast proliferation. In animal models, fish collagen scaffolds have demonstrated successful dural repair with prevention of adhesions, minimal inflammation, and effective CSF leak prevention. These properties suggest that Kerecis™ may promote rapid integration and neodura formation, consistent with the favorable outcome in this patient.
CONCLUSION:
This case demonstrates the novel use of fish-derived ADM for dural repair in a contaminated intracranial wound. Kerecis™ ADM may represent a valuable option for achieving neodura formation. Further research is needed to assess its safety, durability, and broader applicability in neurosurgical reconstruction.