The patient was operated by me 04-June-2014. Radical resection of the pilocytic astrocytoma was achieved and she was kept in the ICU for three days for administrative reasons. The patient was ready for discharge 6 days after surgery, but during discharge preparation, her grandmother told me that some fluid was noted near the dressing. Dressing was done and the wound was clean. Taking this into consideration, the discharge was postponed  for 24 hours to be sure about the wound. The next day the patient started to show meningism with fever and the wound had a pocket under the skin. Aspiration of the wound revealed a huge amount of an orange tea-like CSF. Around 140 ml fluid was evacuated. The patient was covered with Targocid even before surgery with Rocephine. The next day the pocket recollected the same amount and it was aspirated and sent for routine, CXS for aerobic, anaerobic, virological, fungal studies. The next day the CXS revealed Acinetobacter sp. and it was not sensitive nor to Targocid, nor to vancomycin, nor to Rocephine. It was sensitive to Gentamicin, Colistin, Imipnem. These three antibiotics were started and daily dressing with aspiration of the CSF pocket and insertion of Gentamicin continued with parenteral feeding was continued until the CSF became relatively clear and the amount of posterior fossa pocket subsided. MRI of the brain was done 16-June-2014 which showed small hemorrhage at the tumor bed and the right convexity. CSF was sent 21-June-2014 and the result was negative for bacterial growth and the patient started to improve. The patient is 3 year old and the family is not cooperative and the dressing was slipping twice a day. It was decided to perform revision of dura and repair the dural defect to accelerated the discharge of the patient.

In prone position, the old incision was refreshed and the bone flap reflected to the neck. There is a dural defect at the midline inferior junction. A piece of muscle harvested fro the neck muscles was used and 4 zero nylon were used to obtain water-tight closure of the dural defect. Elevation of the head and Valsalva maneuver were applied and no CSF came out. Water-tight closure of the wound.

Smooth postoperative recovery. The patient sent to the ward.

Acinetobacter sp. is a hospital acquired infection. The increase of CSF pressure triggered the creation of dural defect, which is a welcome event in this condition, permitting daily evacuation and continuous cleaning of the infected CSF.

Closure of the dural defect before discharge is mandatory to prevent repetitive mechanical trauma to the brain.