Microfibrillar collagen hemostat–induced necrotizing granulomatous inflammation developing after craniotomy: a pediatric case series

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Microfibrillar collagen hemostat (MCH; trade name Avitene) is a partially water-insoluble acid salt of purified bovine corium collagen. This agent has been widely used to control hemorrhage at surgery, and especially during pediatric neurosurgeries at the authors' institution. Despite its effectiveness, rare case reports detailing adverse inflammatory reactions to MCH have been documented. Based primarily on MR imaging, postoperative reactions have most commonly elicited clinical differential diagnoses of tumor recurrence or abscess. According to the literature, MCH induces a very characteristic mixed inflammatory response that is rich in eosinophils; in light of these observations, many authors have suggested an allergy-based pathogenesis.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors retrospectively reviewed 3 pediatric neurosurgical cases treated at their institution, wherein a common histomorphological inflammatory reaction to MCH was elicited at the site of prior craniotomy.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Case 1 is that of a 10-year-old girl whose diagnosis was a right temporal lobe ganglioglioma, classified as WHO Grade I. Case 2 is that of a 9-year-old boy whose diagnosis was a left parietal lobe anaplastic ependymoma, classified as WHO Grade III. Finally, Case 3 is that of a 15-year-old girl whose diagnosis was focal cortical dysplasia Type IIA affecting the left occipital lobe. Each patient presented with new or recurrent seizures 5–6 weeks after the initial resection. The postsurgical reactions incited by MCH mimicked the radiological appearance of either an abscess (Cases 2 and 3) or recurrent tumor (Case 1). Histologically, the mixed inflammatory infiltrate was typified by the presence of MCH-centric necrotizing granulomas that were surrounded by a palisade of macrophages and often several eosinophils.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The findings are in keeping with previous case reports describing the clinicopathological features of adverse reactions occurring due to MCH. Based on the authors' observations, the possibility of an idiopathic inflammatory reaction to MCH should be considered when either seizures, a typical radiological appearance (that is, consistent with tumor recurrence or abscess formation), or both arise shortly after initial surgery. A conservative treatment approach to this type of inflammatory lesion appears to be the most appropriate management strategy.</jats:p></jats:sec>

Fifty Consecutive Hemispherectomies

“…In the multi-institutional review 52 , the use of any hemostatic agent was a significant risk factor for developing hydrocephalus in the univariate analysis (but not the multivariate analysis). Avitene has been reported to induce granulomatous inflammatory responses post-craniotomy in both patients and animal models 53, 54 . It is possible that this inflammation poses a risk for hydrocephalus similar to that seen in patients with intraventricular infection or hemorrhage.…”

A Textiloma on the Pterion : A Rarely Occurred Craniotomy Complication

“…They are often overlooked or can be confused with other soft-tissue masses. Time to discovery in this case, 8 years, was much longer because of the high likelihood of intracranial textilomas related complications within the first 2 years after surgery1,2,5,6,9). Being sterile, the surgical cottons do not initiate an infective reaction and thus remain clinically silent and missed for a long duration in the postoperative period until they are thought of.…”

“…Among them, textilomas in the fields of neurosurgery have been found to appear after spinal surgery7), craniotomies for trauma6), tumor resection1), clot evacuation9), cotton wrapping of aneurysms5), and microvascular decompression2). The vast majority of reported postcraniotomy textilomas were subdural lesions10).…”

Granulomatous inflammation of dura mater – a rare side effect after application of hemostatic and insulation materials in case of two-stage operation of huge meningioma

“…In our opinion, during planned reconstruction procedures special attention should be paid to persons with a case history related to possible allergies to animal and human proteins, in the context of applying va rious exogenous materials. There are reports sug gesting allergic aetiology caused by heterogeneous collagen used in haemostasis, published after a childneurosurgical procedure [2]. One should also use a local preventive form of avoiding too large quantity of haemostatic agents and artificial insulation materials and, where possible, use an autogenous one.…”

“…Quite often postoperative formation of intracranial granulomas, resulting in a mass effect (space occupying lesions), can mimic tumour recurrence [1,3,8,11,12,15,16]. Allergic reactions to foreign collagen, used in surgery as a haemostatic agent, are also described [2,10].…”