Foreign body reaction to rubber Torkildsen catheters: a report of two cases

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.

Arne Torkildsen and the ventriculocisternal shunt: the first clinically successful shunt for hydrocephalus

Arne Torkildsen was a pioneering Norwegian neurosurgeon who introduced the ventriculocisternal shunt, the first clinically successful shunt for CSF diversion in hydrocephalus. The procedure, usually referred to as ventriculocisternostomy (VCS), Torkildsen's operation, orTorkildsen's shunt, became internationally recognized as an efficient operation for the treatment of noncommunicating hydrocephalus. The operation gained widespread use in the 1940s and 1950s before the introduction of extracranial shunts. In this paper, the authors look more closely at Torkildsen's development of the VCS and examine how this surgical approach differed from other procedures for treating hydrocephalus before World War II. Long-term results of the VCS are presented.

Cerebral Edema Associated with Ventricular Reservoirs in Two Patients: A Case Report

Placement of ventricular reservoirs is a common practice to treat various tumors of the central nervous system (CNS). Ventricular catheter-reservoir-associated edema has been noted in the literature, but a thorough review of this literature identified no articles that examine this particular complication in neurooncology patients, specifically. We report two cases of ventricular catheter-reservoir-associated edema in patients receiving treatment for CNS metastasis.

Torkildsen shunt: re-evaluation of the historical procedure

OBJECTIVE

The Torkildsen shunt, which bypasses the cerebrospinal fluid (CSF) flow from the lateral ventricle to the cisterna magna, has been regarded as a historical procedure. We re-evaluated the clinical usefulness of the Torkildsen shunt as a treatment for hydrocephalus in the era of modern neurosurgery.

MATERIALS AND METHODS

Two hundred seventeen hydrocephalic patients were treated with 494 surgical procedures between April 2002 and April 2009. Among them, five patients (aged 9 months old to 14 years old, followed for 2 months to 4 years) had a Torkildsen shunt. The surgical procedure consists of a parieto-occipital burr hole opening and, if required, C1 partial laminectomy. A ventricular catheter passed subcutaneously bridges the lateral ventricle and the cervical subarachnoid space at the foramen magnum or C1 level.

RESULT

All five patients presented with non-communicating hydrocephalus with a lesion in and around the third ventricle, which precluded endoscopic third ventriculostomy or other endoscopic procedures. The Torkildsen shunt was the first choice treatment in two patients, while three patients had several previous failed CSF diversion surgeries. No complications relating to the surgical procedure occurred. The Torkildsen shunt has been functioning in all but one patient in whom temporary ventricular drainage was added later.

CONCLUSION

The Torkildsen shunt can be effective in selected patients with hydrocephalus even in the era of computed tomography, magnetic resonance imaging, and neuroendoscopy. Although the surgical procedure is technically more demanding, the procedure enables one to avoid a standard ventriculoperitoneal shunt.

Surgical removal of an intramedullary spinal cord foreign body granuloma in a dog

A 2-year-old, spayed female, mixed-breed dog was presented for evaluation of a progressive asymmetric tetraparesis and cranial nerve deficits with a 3-week duration. Computed tomography showed a contrast-enhancing lesion along the left side of the junction of the medulla and the cervical spinal cord. An exploratory surgery determined the presence of an intramedullary lesion of the first cervical spinal cord segment. The mass was removed through a dorsal midline myelotomy. Microscopic examination identified a foreign body granuloma that contained a dense, anisotropic outer wall, supporting the conclusion that the foreign body was of plant origin. The dog recovered to a more improved ambulatory status than prior to surgery.

Foreign body reaction to hemostatic materials mimicking recurrent brain tumor. Report of three cases

Chemical agents routinely used in neurosurgery to achieve intraoperative hemostasis can cause a foreign body reaction, which appears on magnetic resonance (MR) images to be indistinguishable from recurrent tumor. Clinical and/or imaging evidence of progression of disease early after surgical resection or during aggressive treatment may actually be distinct features of granuloma in these circumstances. A series of three cases was retrospectively analyzed for clinical, imaging, surgical, and pathological findings, and the consequences they held for further disease management. All patients were boys (3, 3, and 6 years of age, respectively) and all harbored primitive neuroectodermal tumors. Two tumors were located in the posterior fossa and one was located in the right parietal lobe. Two boys exhibited clinical symptoms, which were unexpected under the circumstances and prompted new imaging studies. One patient was asymptomatic and imaging was performed at planned routine time intervals. The MR images revealed circumscribed, streaky enhancement in the resection cavity that was suggestive of recurrent disease. This occurred 2 to 7 months after the first surgery. At repeated surgery, the resected material had the macroscopic appearance of gelatin sponge in one case and firm scar tissue in the other cases. Histological analysis revealed foreign body granulomas in the resected material, with Gelfoam or Surgicel as the underlying cause. No recurrent tumor was found and the second surgery resulted in imaging-confirmed complete resection in all three patients. Because recurrent disease was absent, the patients continued to participate in their original treatment protocols. All patients remain free from disease 34, 32, and 19 months after the first operation, respectively. During or after treatment for a central nervous system neoplasm, if unexpected clinical or imaging evidence of recurrence is found, a second-look operation may be necessary to determine the true nature of the findings. If the resection yields recurrent tumor, additional appropriate oncological treatment is warranted, but if a foreign body reaction is found, potentially harmful therapy can be withheld or postponed.

Spectrum of clinical and histopathologic responses to intracranial electrodes: from multifocal aseptic meningitis to multifocal hypersensitivity-type meningovasculitis

PURPOSE

We sought to characterize and compare the histopathologic and clinical changes elicited by subdural and depth electrodes in subjects undergoing epilepsy surgery evaluation.

METHODS

A retrospective review of clinical records, imaging and histopathologic studies of epilepsy surgery cases requiring subdural strips and depth electrodes for localization of epileptogenic tissue was performed between 1993 and 1999. Forty-nine subjects had a combination of subdural and depth, whereas 10 had depth electrodes only. Histopathologic changes were classified as mild, moderate, or severe based on the density, extent, and composition of the inflammatory infiltrate.

RESULTS

Subdural electrodes induced a clinical picture of transient aseptic meningitis; histopathologically, the infiltrates were moderate in degree in the majority (73%) and severe in the remainder (27%), with T cells and eosinophils infiltrating the cortex and arteriolar walls (hypersensitivity-type response). Depth electrodes alone caused minimal or no symptoms of meningeal irritation; the cellular response elicited by these electrodes was mild in five and moderate in the remaining five cases; severe inflammation was not observed in this group. Although the proportion of small clinically silent hematomas was larger in cases with depth (five of 59) compared with subdural electrodes (one of 49), microhemorrhages were considerably more numerous with subdural than with depth electrodes.

CONCLUSIONS

These results suggest that the spectrum of brain responses to foreign bodies is wide, ranging from self-limited physiologic to hypersensitivity-type reactions of varying severity. Subdural strips elicited more intense inflammation than did depth electrodes. The histopathologic extent of the reaction to either type of electrodes could not be precisely defined because of the retrospective nature of this study. History of allergy to latex or previous craniotomies are probable risk factors for the hypersensitivity-type reaction. Surgical outcome, excellent in the majority, was independent of the severity or type of inflammation, and there have not been neurologic or systemic sequelae.

Delayed foreign-body reaction to silk sutures in pediatric neurosurgical patients

Nonabsorbable silk sutures have been a frequently used foreign material in neurosurgery. In general, they are reliable and safe with minimal bio-incompatibility. Three pediatric neurosurgical patients came to clinical attention, however, because of delayed foreign-body reactions to silk sutures. The delayed atypical presentation of these patients delayed appropriate diagnosis and therapy. In two patients, the reaction presented as a delayed inflammation 7 years following surgical suture placement. In the other patient, the reaction caused delayed recurrent shunt failures and surgical wound breakdown. These three cases are used to introduce a discussion of the delayed response of the host to foreign material and its pertinence to neurosurgery.

Biological reactions to cerebrospinal fluid shunt devices: a review of the cellular pathology

OBJECTIVE

To understand the interaction between cerebrospinal fluid shunt components and the brain and other tissues.

METHODS

A systematic review of the medical literature directly pertaining to shunt complications, and that dealing with tissues' reactions to implants in general, was conducted.

RESULTS

Vascularized pedicles of glial tissue or choroid plexus grow into ventricular catheters, primarily as a mechanical phenomenon. Cellular debris or blood can cause dysfunction of valve components. Chronic inflammation, which is nonspecific, might contribute to degradation of the components.

CONCLUSION

Care must be taken to prevent early entry of debris or blood into the shunt system. Ventricular collapse onto the shunt must be avoided. Refinement of manufacturing methods or modification of shunt materials could reduce the susceptibility of shunts to infection and improve longevity of the apparatus.