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

Neural tissue tolerance to synthetic dural mater graft implantation in a rabbit durotomy model

In neurosurgical interventions, effective closure of the dura mater is essential to prevent cerebrospinal fluid leakage and minimize post-operative complications. Biodegradable synthetic materials have the potential to be used as dura mater grafts owing to their regenerative properties and low immunogenicity. This study evaluated the safety of ArtiFascia, a synthetic dura mater graft composed of poly(l-lactic-co-caprolactone acid) and poly(d-lactic-co-caprolactone acid), in a rabbit durotomy model. Previously, ArtiFascia demonstrated positive local tolerance and biodegradability in a 12-month preclinical trial. Here, specialized stains were used to evaluate potential brain damage associated with ArtiFascia use. Histochemical and immunohistochemical assessments included Luxol Fast Blue, cresyl Violet, Masson's Trichrome, neuronal nuclei,, Glial Fibrillary Acidic Protein, and ionized calcium-binding adaptor molecule 1 stains. The stained slides were graded based on the brain-specific reactions. The results showed no damage to the underlying brain tissue for either the ArtiFascia or control implants. Neither inflammation nor neuronal loss was evident, corroborating the safety of the ArtiFascia. This approach, combined with previous histopathological analyses, strengthens the safety profile of ArtiFascia and sets a benchmark for biodegradable material assessment in dura graft applications. This study aligns with the Food and Drug Administration guidelines and offers a comprehensive evaluation of the potential neural tissue effects of synthetic dura mater grafts.

Extensive Foreign Body Reaction to Synthetic Dural Replacement After Decompressive Craniectomy with Radiological and Histopathology Evidence: Observational Case Series

BACKGROUND

Though the indications are quite varied, decompressive craniectomy is considered a life-saving procedure. Maximal effectiveness of craniectomy is achieved when, in addition to bone removal, the dura mater is opened properly and is augmented with duraplasty. Different synthetic materials have been used over the decades to replace the dura during decompressive craniectomy. We have used different synthetic dural replacements at our institution, including Neuro-Patch, DuraGen, and Lyoplant. In this case series, we described 4 cases that had excessive granulation tissue formation in response to a newly used synthetic dural substitute (ReDura) after emergent decompressive craniectomy. During follow-up brain imaging at different intervals, these cases were found to have foreign body reaction in the form of excessive granulation tissue formation; additionally, 1 case had a sterile pus-like collection. The granulation tissue diagnosis was affirmed by histopathology in all 4 cases.

METHODS

This study was an observational retrograde case series, with data obtained from electronic medical records.

RESULTS

The study showed extensive foreign body giant cell reactions on preoperative computed tomography scans, indicating a very high occurrence rate of 72.4%, when ReDura was used as dural replacement.

CONCLUSIONS

Our experience showed that patients are prone to develop severe foreign body giant cell reactions with ReDura. Neurosurgical centers using this material should monitor patients for possible abnormal foreign body reaction and report it to establish the safety and efficacy profile of this material.

Injury to the Extrasellar Portion of the Internal Carotid Artery during Endoscopic Transsphenoidal Surgery: A Case Report

Background

Injury to the internal carotid artery (ICA) during endoscopic transsphenoidal surgery (ETSS) is a serious complication with a risk of mortality. ICA injury during ETSS usually occurs during intrasellar manipulations and rarely occurs in the extrasellar portion. Several hemostatic procedures have been proposed for ICA injury in the intrasellar portion, whereas hemostatic methods for ICA injury in the extrasellar portion, where the ICA is surrounded by bone structures, are less well known.

Case Presentation

A 65-year-old man with an incidental pituitary tumor underwent ETSS. The petrous portion of the left ICA was injured during resection of the sphenoid septum connected with left carotid prominence using a cutting forceps. Bleeding was too heavy for simple hemostatic techniques. Hemostasis using a crushed muscle patch was tried unsuccessfully during controlling of the bleeding. Eventually, the injured site of the ICA was covered with cotton patties followed by closing with a vascularized pedicled nasoseptal flap. Cerebral angiography immediately after surgery showed no extravasation from the injured site of the left ICA petrous portion. However, a carotid-cavernous sinus fistula originating from the injured ICA site was detected 7 days after surgery, so the vascular reconstructive surgery combined with left ICA occlusion was performed. The overall postoperative course was uneventful.

Conclusion

We believe that emergency application of the cottonoids may be effective for hemostasis against ICA injury in the extrasellar portion during ETSS, but further vascular reconstruction combined with ICA occlusion on the injured side and removal of the cottonoids would be required.

Foreign body reaction mimicking local recurrence from polyactide adhesion barrier film after laparoscopic colorectal cancer surgery: A retrospective cohort study

Polyactide (PLA) barrier is one of the most commonly used materials to prevent the formation of postoperative adhesion. Even though previous studies supported the anti-adhesion efficacy of PLA barrier, there have been limited reports focusing on the associated foreign body reaction. We sought to investigate the potential complication of PLA barrier placement that could lead to unnecessary intervention.This is a retrospective study of colorectal cancer patients with laparoscopic surgery. Cases with stage IV unresectable disease, poor Eastern Cooperative Oncology Group Performance, death within 3 months after the surgery, and insufficient record were excluded. A total of 296 cases were identified in our study and 220 patients received PLA film placement. We compared the incidence of foreign body reaction between the patients with and without PLA film.Among PLA film group, 16 cases had signs of local recurrence on the follow-up image studies. The subsequent operation found 10 patients had no cancerous lesions but only foreign-body-associated granulomas. The incidence of foreign body reaction mimicking local recurrence on image study was 4.5% with high false positive rate of 62.5% on positron emission tomography scan in patients with PLA film. There were only 2 cases without the antiadhesive barrier developed signs of recurrence during active surveillance. Both cases were later confirmed to have malignant peritoneal seeding.The PLA film was associated with rare foreign body reaction that could interfere the accuracy of follow-up program and result in unnecessary surgical intervention. Hence, we recommend avoiding the use of the PLA barrier.

Foreign body granuloma around implantable pulse generator for deep brain stimulation: Two case reports

We report two cases of granuloma that occurred around an implantable pulse generator (IPG) for deep brain stimulation. Both cases showed no signs of infection and disappeared after moving the IPG and removing the granulation. If a noninfectious mass is formed, the relocation of IPG may improve it.

Bone Fragment Granuloma Mimicking a Brain Tumor Following Placement of an Intracranial Pressure Monitoring System

The placement of intracranial pressure (ICP) monitoring system requires drilling an orifice in the skull. Bone fragments can accidentally be inserted into the brain parenchyma while introducing the ICP monitoring system during the procedure. An intracranial granuloma can be subsequently formed if a non-specific reaction is induced and maintained by the inserted bone fragment in the brain parenchyma. These intracranial granulomas may eventually be confused with brain masses on follow-up imaging studies. We present the case of a 65-year-old male who underwent cranial surgery secondary to a severe traumatic brain injury (TBI). An intracranial bolt was initially placed contralaterally to measure the ICP. Eleven years later, a granuloma from a retained bone fragment secondary to the intracranial bolt placement was suspected. The clinical course, radiological investigations, and differential diagnosis are presented.

Extradural abscess following synthetic fabric duraplasty

Background:

Duraplasty refers to the neurosurgical process of reconstructing dural defect. Variety of materials is used for such reconstruction, including natural, semisynthetic, and synthetic materials. Although synthetic materials are readily available and easy to apply, these are associated with foreign body reaction which may lead to serious consequences in some cases. We describe one such rare instance of extradural abscess after polypropylene synthetic fabric duraplasty.

Case Description:

Our patient is a 33-year-old lady who suffered road traffic accident leading to massive brain laceration, contusion of bilateral frontal lobes, and anterior skull base fractures. Emergency craniotomy was carried out and dural defect repaired with polypropylene (G-Patch; G. Surgiwear^® Ltd.) synthetic fabric as the duraplasty material. Three months later, the patient presented with discharging wound at the incision site. Neuroimaging showed ring enhancing lesion in frontobasal extradural space with cutaneous extension. The lesion failed to heal despite intravenous antibiotics and surgery was planned. Intraoperatively, abscess was found between G-Patch and dura. Histopathology showed granulomatous foreign body reaction. The lesion healed after synthetic dura removal and abscess drainage.

Conclusion:

Although various materials are used for duraplasty, there is no clear consensus on what material should be used for dural repair. Synthetic materials are bio-inert, offer good handling and malleability. Polypropylene has been used safely for both single- and double-layered duraplasty. However, foreign body reaction may occur and very rarely present as extradural abscess. Randomized trials should be done to establish the safety and efficacy profile of commonly used duraplasty materials.

Intracranial Foreign Body Granuloma Mimicking Brain Tumor Recurrence: A Case Series

BACKGROUND

Intracranial foreign body granuloma (FBG) is a rare inflammatory reaction to retained foreign material, manifesting acutely or months to years following neurosurgical procedures. Radiographically, FBG can mimic tumor progression, and tissue biopsy may be required to guide management.

MATERIALS AND METHODS

In this retrospective case series, we present unique clinico-radiographic and histopathological features of six neuro-oncological patients diagnosed with FBG between 2007 and 2019.

RESULTS

All six patients (4 women and 2 men, aged 29-54 [median, 30.5] years) had undergone surgical resection of a low- (n = 4) or high-grade (n = 2) glioma. FBG manifestation postsurgery ranged from 1 day to 4 years and was predominantly asymptomatic (n = 5/6). Magnetic resonance imaging universally demonstrated one or multiple peripherally enhancing lesion(s) adjacent to the resection cavity. Histopathology in all (n = 4/4) resected specimens demonstrated an inflammatory reaction to foreign material, confirming FBG.

CONCLUSION

Intracranial FBG constitutes a rare but challenging treatment-related condition effectively managed by surgery, with important therapeutic implications in neuro-oncology.

MRI findings for diagnosis of postoperative foreign body granulomas versus recurrent tumours in patients of brain tumour surgery

AIM

To evaluate the postoperative magnetic resonance imaging (MRI) findings of intracranial foreign body granulomas (FBGs) and true recurrent tumours (RTs) and thus lead to a basis for management decision-making.

MATERIALS AND METHODS

Twenty-two patients with previous brain tumour surgery were diagnosed clinically with RT and underwent surgery. Re-operative pathology revealed FBG in eight patients and RT in 14 patients. MRI findings before the initial operation were compared to those before the re-operation.

RESULTS

Features of FBGs versus RTs on MRI were as follows: (1) mean lesion size: 1.3 ± 0.7 (0.5-2.6) versus 3.2 ± 1.7 (1.1-6.3) cm (p=0.001, odds ratio [OR] = 4.18); (2) hypointensity on T2-weighted imaging (WI): 6/8 (75%) versus 0/14 (0%; p<0.001, OR=75.4); (3) non-restricted diffusion on diffusion-WI (DWI): 6/8 (75%) versus 2/14 (14.3%; p=0.008, OR=18); and (4) "ring and bubble" appearance on contrast-enhanced T1WI: 7/8 (87.5%) versus 2/14 (14.3%; p=0.001, OR=42). In comparison with their original tumours, the FBGs in the FBG group showed significantly lower T2 signal intensity, lower signal on DWI, and more cases of non-restricted diffusion on DWI (p=0.04, 0.04, 0.04, respectively).

CONCLUSION

On brain MRI, FBGs can be differentiated from RTs by their relatively smaller size, hypointensity on T2WI, lack of restricted diffusion on DWI, and "ring and bubble" appearance on contrast-enhanced T1WI. Comparing the MRI findings of the focal lesion in the tumour bed with those of the original tumour is suggested to enhance diagnostic confidence.

Spontaneous necrotizing granuloma of the cerebellum: a case report

Background

Intracranial necrotizing granulomatous space-occupying lesions are sparsely reported in literature. Variability in presenting symptomatology and radiographic features makes diagnostic work-up difficult.

Case presentation

This report presents the case of a 77-year-old female with sinusitis and fatigue who underwent an MRI revealing a posterior fossa lesion compressing the fourth ventricle. Subsequent contrast CT of the chest, abdomen, and pelvis was negative for primary malignancy. Histopathologic examination of the lesion following biopsy showed it to be a necrotizing granuloma in an antineutrophil cytoplasmic antibody (ANCA) negative patient. The most likely diagnosis was determined to be spontaneous necrotizing granuloma, a rare entity with only one previous report noted.

Conclusions

Spontaneous necrotizing granuloma of the CNS is a rare entity that represents an important differential consideration in the work-up of space occupying lesions of the CNS.

Cerebral Granuloma Mimicking Malignant Neoplasm in Patient with Seizures 21 Years After Head Trauma

BACKGROUND

Chronic posttraumatic cerebral granuloma is a rare, delayed complication of traumatic brain injury. Because of its late onset of symptoms and atypical appearance, the correct diagnosis of this rare lesion is difficult.

CASE DESCRIPTION

A 49-year-old man presented with seizures, which occurred 21 years after open right forehead trauma. Imaging techniques, such as magnetic resonance imaging and magnetic resonance spectroscopy, which indicated a malignant neoplasm, revealed a mass lesion on the right frontal lobe, invading the dura and partial frontal bone. The patient underwent total removal of the lesion and titanium mesh cranioplasty, simultaneously, due to invasion of the mass lesion into the skull. However, the postoperative histopathologic diagnosis was chronic inflammatory granuloma. At 1-year follow-up, he did not have any discomfort and epilepsy did not recur.

CONCLUSIONS

Chronic cerebral granuloma should be considered in the differential diagnosis of a novel or recurrent mass detected in patients with a history of traumatic brain injury or prior surgery. Moreover, the retained foreign bodies in the superficial or nonfunctional area of the brain should be thoroughly examined and removed at the time of injury, particularly in open brain trauma.