Granuloma formation and occlusion of an unruptured aneurysm after wrapping

Use of Oxidized Regenerated Cellulose as a Hemostatic Agent in Neurosurgery: Appraisals and Recommendations to Prevent Postoperative Complications and Facilitate Follow-Up

Neurosurgical hemostasis can be performed with bipolar coagulation and with the support of several dedicated biomaterials including oxidized regenerated cellulose (ORC; e.g., Surgicel®, Johnson & Johnson, New Brunswick, NJ, USA). Oxidized regenerated cellulose is a sterile absorbable fibrous biomaterial that has become a major local hemostatic agent thanks to its ease of use, favorable biocompatibility and bioabsorption characteristics. However, some postoperative issues associated with its use, such as allergic reaction, seroma, foreign-body reaction with compressive neuropathies and misdiagnosis during follow-up, have been reported. These complications could compromise clinical outcomes with a negative impact on patient quality of life and sometimes require risky major surgical procedures. An understanding of the specific properties of ORC combined with adequate surgical expertise and compliance with some basic rules are needed to optimize clinical outcomes and minimize postoperative issues.

Intracranial foreign material granulomas after cranial surgery

BACKGROUND

Various synthetic materials are used in neurosurgery and left in place intentionally during surgery for several purposes such as hemostasis, dural closure, or cranioplasty. Although leaving such substances in surgical sites is considered safe, in general, foreign body granuloma may occur months or years after intracranial surgery. Thus, far relatively little is known about treatment and outcome of such lesions.

METHODS

A systematic review of 3466 histopathological examinations after cranial surgeries achieved over a 13-year period was performed. After excluding patients with Teflon granulomas or infection, a total of 12 patients with foreign body granulomas induced by synthetic material used in a prior surgery were identified. Patient records, imaging studies, and histopathological data were analyzed. Furthermore, postoperative outcome was assessed.

RESULTS

Mean age at the second surgery was 51 years (range, 11-68 years). The median time between the primary and the secondary surgery was 13 months (range, 1-545 months). Eight patients (75%) presented with signs and symptoms related to the foreign body granulomas. Total resection of the foreign body granulomas was performed in all patients. The granulomas were induced by oxidized cellulose polymer (n = 6), suture material (n = 3), Gelfoam (n = 1), methylmethacrylate (n = 1), and bone wax (n = 1). The mean postoperative follow-up time was 54 months (range 1-137 months). There was symptomatic improvement in all instances. Imaging studies did not demonstrate any recurrence.

CONCLUSION

Despite its rarity, foreign body granuloma should be taken into consideration in the differential diagnosis of intracranial mass lesions especially in cases of suspected tumor recurrence after prior surgery. The pathogenesis of foreign body granuloma still needs further clarification. Our study demonstrates that they have good prognosis after surgical removal.

Foreign Body Granuloma After Cranial Surgery: A Systematic Review of Reported Cases

BACKGROUND

In cranial surgery, different foreign body (FB) materials are used and may be left intentionally or unintentionally in the surgical field after closure, inducing a foreign body granuloma (FBG). This is a rare complication in neurosurgery, but it may be a diagnostic dilemma, with sometimes medicolegal implications.

METHODS

We performed a systematic review of the English literature between 1965 and 2018 and found a total of 77 articles concerning 100 cases of FBG caused by retained material located within the cranium or surrounding soft tissues.

RESULTS

There were 60 females and 40 males, with ages ranging from 1 to 77 years. Most initial diagnoses were cranial/intracranial tumors, trigeminal neuralgia, hemifacial spasm, intracranial aneurysm, hydrocephalus, head injury, infectious disease, and nontraumatic intracerebral hematoma. The interval from the causative surgical operation to presentation of the FBG ranged from 2 weeks to 20 years. Various radiologic modalities were used and histologic study confirmed the presence of FBG in all patients. Intentional FB was used and left in 77 patients, and unintentional FB was found postoperatively in 23 patients. Associated infection was found in 13 patients. Complete recovery was seen in 47.6% of patients with sufficient data.

CONCLUSIONS

Despite being unusual, a retained FBG should be considered in the differential diagnosis of any patient after cranial surgery. A history of surgery, clinical symptoms, physical examination findings, laboratory results, and the use of appropriate neuroimaging explorations may provide a correct preoperative diagnosis. In addition, unintentionally retained FBs are preventable errors in the operating room.

Surgical treatment of a gauzoma with associated obliterative arteriopathy and review of the literature

We report a case of a 50-year-old woman whose 0.5 mm middle cerebral artery (MCA) aneurysm was treated with gauze wrapping at an outside facility. She returned 9 months later with seizures and an inflammatory process in the region of the prior aneurysm. Surgical re-exploration at that time was aborted. Two years later, she presented with a gauzoma associated with local inflammatory response and severe narrowing of the MCA. A common carotid artery to MCA bypass was performed, followed by surgical removal of the gauze and inflammatory material. Over a 3-month period, she recovered with significant improvement in her preoperative neurological deficits.

Multiple brain abscesses caused by infection with Candida glabrata: A case report

The present case report described the initial diagnosis of a 25-year old female with a brain abscess consisting of two lesions 0.2 and 2.9 cm³ in volume. The patient was initially treated with antibiotics; however, 2 months following initial treatment, the patient's condition deteriorated and she became vegetative. Following transfer to the China-Japan Union Hospital of Jilin University (Jilin, China) the two lesions had grown in volume to 9.0 and 13.0 cm³, respectively. The results of magnetic resonance spectroscopy and plasma 1–3-β-D-glucan activity suggested a possible fungal infection. Subsequently, a stereotactic biopsy was conducted, fluid was cultured and itraconazole treatment was initiated. Analysis of cultures confirmed a Candida glabrata infection and antifungal treatment was continued. Shortly following surgery, the patient regained consciousness and the ability to eat and speak. A follow-up MRI 8 months following biopsy confirmed disappearance of all lesions and no recurrence. To the best of our knowledge, this is the first English-language report of a brain abscess caused primarily by Candida glabrata.

Long-term MRI findings of muslin-induced foreign body granulomas after aneurysm wrapping. A report of two cases and literature review

Muslin-induced foreign body granulomas are rare delayed complications after wrapping of intracranial aneurysms. Few small case series have been reported, with a paucity of documented MRI findings. In addition, there are no reports on long-term radiological appearances or temporal evolution of conservatively managed patients. We thus report on the long-term radiological and clinical follow-up of two patients with asymptomatic muslin-induced foreign body granulomas after wrapping of recurrent middle cerebral arterial aneurysms. Both patients were successfully managed conservatively and remain asymptomatic three and six years after diagnosis of their granulomas. A literature review confirms that MRI features of muslin-induced foreign body granuloma are typical. Features include focal areas of elevated T2 signal with increased diffusion-weighted signal and thin rim enhancement. To the best of our knowledge, this is the first report to confirm that there is a corresponding reduction in apparent diffusion coefficient, as typical in an intracranial abscess. Thus a history of aneurysm wrapping is critical for diagnosis. Accurate clinical recognition of this exuberant inflammatory response will avoid misdiagnosis as pyogenic abscess or tumor and prevent unnecessary or invasive treatment.

Long-term follow-up of ruptured intracranial aneurysms treated by microsurgical wrapping with autologous muscle

The purpose of this study is to describe our series of nine unclippable and uncoilable ruptured aneurysms in eight patients treated by microsurgical wrapping with autologous muscle. Records were retrospectively reviewed for rebleeding rate, morbidity and mortality, changes in size or the aneurysm's configurations, and inflammatory reaction. We conducted a Medline search in the post-microsurgical era, excluding patients in whom wrapping was part of the aneurysm treatment in combination with clipping or coiling. The surgically related morbidity was 12.5%. Global mortality rate was 25% due to vasospasm (one case) and rebleeding (one case). Six patients are still alive. Rebleeding rate was 14.3% within 6 months; then, it was zero. Glasgow outcome scale (GOS) score at discharge was 1 and 4 in one patient, respectively, and 5 in the remaining six. Mean clinical follow-up was 126 months. GOS at last follow-up was 4 and 5 in 50% of patients, respectively. Mean mRS score was 0.8 at 2 months, and 2.4 at 12 months. Follow-up MR demonstrated persistence of the aneurysm's sac, without changes in size and configuration. Patients did not describe or exhibit symptoms attributable to complications inherent to the use of muscle. Microsurgical muscle-wrapping of ruptured intracranial aneurysm is safe, is associated with a low rate of acute and delayed postoperative complications and rebleeding, and could be a valid alternative for unclippable and non-amenable to endovascular procedure ruptured aneurysms.

First human model of in vitro Candida albicans persistence within granuloma for the reliable study of host-fungi interactions

Backgound

The balance between human innate immune system and Candida albicans virulence signaling mechanisms ultimately dictates the outcome of fungal invasiveness and its pathology. To better understand the pathophysiology and to identify fungal virulence-associated factors in the context of persistence in humans, complex models are indispensable. Although fungal virulence factors have been extensively studied in vitro and in vivo using different immune cell subsets and cell lines, it is unclear how C. albicans survives inside complex tissue granulomas.

Methodology/Principal Finding

We developed an original model of in vitro human granuloma, reproducing the natural granulomatous response to C. albicans. Persistent granulomas were obtained when the ratio of phagocytes to fungi was high. This in vitro fungal granuloma mimics natural granulomas, with infected macrophages surrounded by helper and cytotoxic T lymphocytes. A small proportion of granulomas exhibited C. albicans hyphae. Histological and time-lapse analysis showed that C. albicans blastoconidia were located within the granulomas before hyphae formation. Using staining techniques, fungal load calculations, as well as confocal and scanning electron microscopy, we describe the kinetics of fungal granuloma formation. We provide the first direct evidence that C. albicans are not eliminated by immunocompetent cells inside in vitro human granulomas. In fact, after an initial candicidal period, the remaining yeast proliferate and persist under very complex immune responses.

Conclusions/Significance

Using an original in vitro model of human fungal granuloma, we herein present the evidence that C. albicans persist and grow into immunocompetent granulomatous structures. These results will guide us towards a better understanding of fungal invasiveness and, henceforth, will also help in the development of better strategies for its control in human physiological conditions.

[Candida albicans cerebral granuloma in an immunocompetent patient. A case report]

We report a case of temporal lobe granuloma caused by Candida albicans in an immunocompetent patient. This 54-year-old patient had experienced headaches and some memory disorders for two to three months before his admission to the neurosurgical department. Cerebral-computer tomography and magnetic resonance imaging showed a single right-temporal lesion with a large peritumoral edema. We operated on the patient via a temporal approach using neuronavigation and resected the lesion. The anatomopathological result and the cultures of the granuloma showed C. albicans species. The patient received antifungal therapy for three months. No predisposing factors or immunosuppression was found. After seven months, he presented an ischemic cerebrovascular accident of the brain stem and then chronic meningitis complicated by hydrocephalus. The patient's condition progressively deteriorated and he died 18 months later in an other department. C. albicans can be found even in the immunocompetent patient, but is seldom observed. Surgery can provide an accurate diagnosis and therapeutic management in the initial phase, completed by antifungal therapy.