Introduction: Pseudomeningoceles are common complications after surgery. These lesions may present with pain, intracranial hypotension, and CSF leak related infection. Management guidelines are lacking and anecdotally we have encountered suggested treatments with significant potential morbidity. With this study we hope to determine the prevailing opinions on the management of this condition.

Methods: Neurosurgeons from around the world were invited to participate in a 33-question survey that simulated settings where pseudomeningoceles may be seen and clinical equipoise exists with regards to management.

Results: 241 responses were obtained. When faced with a cranial pseudomeningocele without hydrocephalus, most would manage conservatively for an average of 7 to 14 days before taking the patient to the operating room for a definitive repair. The development of hydrocephalus or wound breakdown is indication for alternative management. In the presence of ventriculomegaly, respondants were divided between inpatient observation and ETV. Physicians would only observe for 2 - 4 days on average before shunting these patients. Hydrocephalus and wound breakdown were again the most common indications for alternative management. Neurosurgeons were also divided on the management of spinal pseudoemeningoceles with relatively even proportions discharging patients, observing as inpatients, and aspirating the collection. Again neurosurgeons waited an average of 7 – 14 days before attempting an alternative treatment. If initial therapy failed, most felt that operative revision would be the most appropriate treatment.

Conclusions: We hope that this study generates discussion surrounding a commonplace topic in many practices. The present zeitgeist suggests that initial observation in the absence of ventriculomegaly is appropriate for cranial and spinal pseudomeningoceles. Operative revision should be reserved for failure of initial management. If ventriculomegaly is present, consideration should be made for upfront CSF diversion. We believe that this study may serve as a guideline regarding acceptable management.

Patient Care: By understanding the prevailing opinions regarding management, a standardized guideline maybe developed for the management of pseudomeningoceles. In doing so, the risk of potential morbidity associated with unnecessary procedures or inappropriate treatments may be avoided.

Learning Objectives: By the end of the session, participants should be able to: 1) define a pseudomeningocele; 2) identify some common complications associated with pseudomeningoceles; 3) discuss current treatment strategies for pseudomeningoceles; 4) identify the current zeitgeist on management of cranial and spinal pseudomeningoceles

References: 1) Ghavanini AA, Scott CA, Chan DK, Tang-Wai DF: Management of patients with spontaneous intracranial hypotension causing altered level of consciousness: report of two cases and review of literature. Cephalalgia 33:43–51, 2013 2) Hillier CE, Stevens AP, Thomas F, Vafidis J, Hatfield R: Aseptic meningitis after posterior fossa surgery treated by pseudomeningocele closure. J Neurol Neurosurg Psychiatry 68:218–9, 2000 3)Hoffman RA: Cerebrospinal fluid leak following acoustic neuroma removal. Laryngoscope 104:40–58, 1994 4) Manley GT, Dillon W: Acute posterior fossa syndrome following lumbar drainage for treatment of suboccipital pseudomeningocele. Report of three cases. J Neurosurg 92:469–74, 2000