Postoperative Textiloma Mimicking Intracranial Rebleeding in a Patient with Spontaneous Hemorrhage: Case Report and Review of the Literature.

During craniotomy, hemostatic materials such as oxidized cellulose and cotton pads, commonly used to control bleeding, may cause a granulomatous reaction that may produce space-occupying mass lesions termed textiloma (or gossypiboma). We present a 46-year-old female who underwent a right frontotemporal craniotomy and surgical removal of intraparenchymal cerebral hemorrhage, and who developed a textiloma during the postoperative period causing seizures. Granulomatous reactions due to hemostatic agents have been reported experimentally, as well as after cranial and spinal operations. We emphasize that although it is rare, an adverse reaction such as a postoperative textiloma due to hemostatic material and subsequent granuloma formation can result in a false image of rebleeding, tumor recurrence, radiation necrosis, or postoperative abscess, depending on the particular clinical history of each patient.

Introduction

During craniotomy, hemostatic materials such as oxidized cellulose and cotton pads are used to control bleeding. Hemostatic materials commonly used for hemostasis may cause a granulomatous reaction that may produce space-occupying mass lesions termed textiloma (or gossypiboma) that are clinically or radiologically apparent. Intracranial body granuloma reactions initially provoke no clinical symptoms, but they may appear months or even years after surgical procedure [1, 2, 3, 4]. All classes of hemostatic agents may cause a granulomatous reaction that may mimic recurrent or progressive intracranial tumor, radiation necrosis, abscess, resolving infarction, or intracranial rebleeding on postoperative imaging studies, depending on the particular clinical history of each patient.

Case Presentation

A 46-year-old female, with no significant past medical and surgical illnesses, was admitted to our Department of Neurosurgery because of left hemiplegia followed by secondary generalized seizures. A computed tomography (CT) scan of the head showed the presence of a spontaneous right frontotemporal intraparenchymal cerebral hemorrhage. The patient underwent a right frontotemporal craniotomy and surgical removal of the intraparenchymal cerebral hemorrhage; an anticonvulsive medication was started. Blood tests did not show increased inflammatory parameters, merely a mild leukocytosis. Ten days after surgery, the patient started to develop subsequent seizures. A postoperative CT scan showed a small hyperdense mass lesion in the surgical cavity mimicking a minimal intracranial rebleeding (Fig. 1a). A follow-up CT brain scan 20 days after surgery showed persistence of the small hyperdense mass lesion (Fig. 1b). Subsequent magnetic resonance imaging (MRI) scans revealed a contrast hyperintense enhancing mass at the surgical site (Fig. 1c, d), suggestive of textiloma, developed during the postoperative period following surgery and the cause of seizures. A clinical follow-up 3 months later showed the patient had a good recovery with no seizures, even if a slight left hemiparesis persisted.

Fig. 1

Postoperative axial CT scan (a) shows a hyperdense mass lesion in the surgical cavity. A follow-up brain CT scan 20 days after surgery (b) shows persistence of the hyperdense mass lesion. Postoperative axial gadolinium-enhanced T1-weighted (c) and axial T2-weighted (d) MRI show enhancement of the textiloma.

Discussion

Chemical hemostatic materials (gelatin sponge, oxidized cellulose, and microfibrillar collagen) are used to achieve hemostasis during neurosurgical procedures. Gelatin sponges were introduced into surgical practice more than 50 years ago. Since that time granulomatous reactions to gelatin foam (Gelfoam), as well as to oxidized cellulose (Oxycel), oxidized regenerated cellulose (Surgicel), microfibrillar collagen (Avitene), or nonabsorbable materials including various forms of cotton pledgets and cloth (such as muslin), have been reported after neurosurgical operations [1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14]. These agents are usually removed prior to surgical closure, except in the case of muslin, which is used to reinforce unclippable intracranial aneurysms [12]. Granulomatous reactions due to hemostatic agents have been reported experimentally [15], as well as after cranial [1, 4, 5, 6, 8, 9, 11, 12, 13, 14] and spinal [1, 10, 16] operations. Fibrin sealant has not been reported in the neurosurgical literature as the source of a granulomatous reaction [9]. Textiloma (from Latin textile, a woven fabric, plus the suffix oma, meaning swelling or tumor), gossypiboma (from Latin Gossypium, the genus of cotton plants), gauzoma (from surgical gauze), and muslinoma (from muslin, a woven cotton fabric) are all terms that describe foreign body-related inflammatory pseudo-tumors [1]. These terms refer to mass effect brain lesion arising from retained, absorbable or nonabsorbable hemostatic agents used during surgery, together with the associated inflammatory reaction. In current neurosurgical practice, textiloma, which has an historical precedence denomination in preference to gossypiboma, often refers to a resorbable hemostatic agent that is intentionally left in place to prevent the potentially disastrous consequences of postoperative intracranial hemorrhage. Textilomas may present at any time, from immediately postoperatively to several decades after initial surgery [17, 18]. In this case report, oxidized regenerated cellulose, which is commonly used during surgery to obtain a good hemostasis, was the cause of the foreign body reaction. In the general surgical literature, the incidence of textiloma is highest following abdominal surgery, followed by orthopedic procedures. Textilomas have been reported in all major anatomic compartments: chest, retroperitoneum, extremities, head, and neck [4]. Granulomatous reactions in the head to foreign bodies such as suture material [19], cotton pads [5, 8, 15], cadaveric [20] or synthetic [21] dural grafts, and shunt catheters [22] have been described in numerous publications. Histologic examination typically shows a core of degenerating hemostatic agent surrounded by an inflammatory reaction [4]. Ribalta et al. [4] reported variable proportions of acute and chronic inflammatory cells, foreign body giant cells, collagen deposition, reactive vascular proliferation, and degenerated foreign material in their cases. Resorbable hemostatic agents are used in all craniotomies at our institution. The pathologic reaction described in this paper represents a rare case considering the large number of patients in whom such materials are used and sometimes left during surgery. Nevertheless, it is important to recognize that all the manufacturers of these agents recommend removal of the material once hemostasis is achieved. The increasing use of MRI monitoring enables the opportunity to study these granulomatous reactions. Despite the importance of MRI in the diagnosis of textiloma or gossypiboma, the diagnosis must be reached by radiological suspicions, as also by intraoperative findings.

Conclusion

In patients with a history of cranial operation, textiloma (although no pathognomonic radiologic characteristics are defined for these lesions) should be taken into account in the differential diagnosis when a hyperdense mass lesion is found after surgery, as it is believed that they are much more common than reported [23]. Gelatin sponge, oxidized cellulose, oxidized regenerated cellulose, and microfibrillar collagen, if properly used, are excellent and essential tools for safe control of minor bleeding in neurosurgery. We emphasize that although it is rare, an adverse reaction such as a postoperative textiloma (gossypiboma) due to hemostatic material and subsequent granuloma reaction can result in a false image of rebleeding, tumor recurrence, radiation necrosis, or postoperative abscess.

Statement of Ethics

The patient provided both oral and written informed consent for the publishing of this report.

Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors did not receive any funding support.

Author Contributions

N.M. carried out the literature search and performed the manuscript preparation. D.M., B.R., and A.I. collected the clinical and surgical data. All authors read and approved the final manuscript.