Intracranial foreign body granuloma caused by dural tenting suture

Recovery after inadvertent intramedullary microchip implantation at C1–C2 in a kitten

Case summary

A 15-week-old male British Shorthair cat was presented for peracute paralysis immediately after microchip implantation. Neurological examination revealed a non-ambulatory tetraparesis and left thoracic limb plegia localised to C1–C5 spinal cord segments. CT of the cervical spine showed a diagonally orientated metallic foreign body (microchip transponder, 10 mm in length) within the vertebral canal at the level of C1–C2, resulting in a penetrating spinal cord injury. Based on concerns about further iatrogenic spinal cord injury through surgery, medical management was chosen. Despite the severe clinical signs, the kitten returned to ambulation within 6 days of the injury, with controlled urination and defecation. Continuous neurological improvement was seen for up to 6 weeks after the injury at which point a mild-to-moderate ambulatory tetraparesis and ataxia remained, with an overall good quality of life. Follow-up CT at the age of 13 months revealed a relative cranial displacement and rotation of the microchip towards the foramen magnum, while the cat’s neurological status was unchanged.

Relevance and novel information

This case demonstrated a cervical penetrating spinal cord injury in a growing cat caused by a microchip, which was successfully managed with medical treatment, suggesting that this might be an option for patients at risk of severe surgery-related complications or where owners reject surgery.

Is Placing Prophylactic Dural Tenting Sutures a Dogma?

OBJECTIVE

In this study, we investigated if and when dural tenting sutures are necessary during craniotomy.

METHODS

Results from 437 patients 18-91 years of age (average, 43.5 years) who underwent supratentorial craniotomy between 2014 and 2019 were evaluated. The patients were categorized into 1 of 3 groups: patients who had at least 3 prophylactic dural tenting sutures placed before opening of the dura (group 1); patients who had at least 3 dural tenting sutures placed after surgery was completed, during closure (group 2); or patients who had no dural tenting sutures (group 3 [control]). All such sutures in groups 1 and 2 were placed in the circumference of the craniotomy and dural junction. No central dural tenting sutures were placed in any of the patients.

RESULTS

Among the 437 patients, 344 underwent surgery for the first time and 93 were undergoing a second surgery. Cranial computed tomography imaging was performed for each patient 1 hour, 3 days, and 1 month after surgery. In group 1, 3 patients had a cerebral cortex contusion and 2 patients had acute subdural hematoma after the sutures were placed. In groups 2 and 3, none of the patients had a cerebral cortex contusion or acute subdural hematoma. Fewer complications were observed when dural tenting sutures were placed during postsurgical closure.

CONCLUSIONS

Placing dural tenting sutures is an important technique for ensuring hemostasis. However, when not needed, they seem to cause inadvertent complications. As our results suggest, knowing when and where to use them is equally important.

Intruding implements: a pictorial review of retained surgical foreign objects in neuroradiology

Intra-cranial and spinal foreign body reactions represent potential complications of medical procedures. Their diagnosis may be challenging as they frequently show an insidious clinical presentation and can mimic other life-threatening conditions. Their pathophysiological mechanism is represented by a local inflammatory response due to retained or migrated surgical elements. Cranial interventions may be responsible for the presence of retained foreign objects represented by surgical materials (such as sponges, bone wax, and Teflon). Spinal diagnostic and therapeutic procedures, including myelography, chordotomy, vertebroplasty, and device implantation, are another potential source of foreign bodies. These reactions can also follow material migration or embolization, for example in the case of Lipiodol, Teflon, and cement vertebroplasty. Imaging exams, especially CT and MRI, have a central role in the differential diagnosis of these conditions together with patient history. Neuroradiological findings are dependent on the type of material that has been left in or migrated from the surgical area. Knowledge of these entities is relevant for clinical practice as the correct identification of foreign bodies and related inflammatory reactions, material embolisms, or migrations can be difficult. This pictorial review reports neuroradiological semeiotics and differential diagnosis of foreign body-related imaging abnormalities in the brain and spine.

Necessity of dural tenting sutures in modern neurosurgery: protocol for a systematic review

INTRODUCTION

The ongoing need for dural tenting sutures in a contemporary neurosurgical practice has been questioned in the literature for over two decades. In the past, these sutures were supposed to prevent blood collecting in the potential space between the skull and the dura by elevating the latter. Theoretically, with modern haemostasis and proper postoperative care, this technique should not be necessary and the surgery time can be shortened. Unfortunately, there is no evidence-based proof to either support or reject this hypothesis.

METHODS AND ANALYSIS

The systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and The Cochrane Handbook for Systematic Reviews of Interventions. Eight electronic databases of peer-reviewed journals will be searched, as well as other sources. Eligible articles will be assessed against inclusion criteria. The intervention is not tenting the dura and this will be compared with the usual dural tenting sutures. Where possible, 'summary of findings' tables will be generated.

ETHICS AND DISSEMINATION

Ethical committee approval is not required for a systematic review protocol. Findings will be presented at international neurosurgical conferences and published in a peer-reviewed medical journal.

PROSPERO REGISTRATION NUMBER

CRD42018097089.

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.

Tissue reactions of abdominal integuments to surgical sutures in sonography

Classical abdominal surgeries usually require long incisions of the abdominal integuments followed by tight closure with adequate suturing material. Nonabsorbable sutures may cause various reactions, including granuloma reactions, both sterile and inflammatory.