Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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February 25, 2021
Intracranial Gossypiboma/Textiloma
- Background:
- Textiloma, gossypiboma, gauzoma (from surgical gauze), and muslinoma (from muslin, a woven cotton fabric) are the historical terms that have been given to foreign body–related inflammatory/granulomatous pseudotumors arising from inadvertently or deliberately retained nonabsorbable surgical materials.
- A variety of hemostatic agents are routinely used to control intraoperative bleeding in neurosurgery. Nonresorbable materials include various forms of cotton pledgets, cloth (such as muslin), and synthetic rayon hemostats (cottonoids and kites). These agents are removed prior to surgical closure, except in the case of muslin, which is used to repair or reinforce intracranial aneurysms.
- After surgery, the body reacts to foreign bodies such as retained sponges in 2 ways: 1) exudative tissue reaction, which leads to acute abscess formation and 2) aseptic fibrous tissue reaction, which involves slow adhesion formation such as encapsulation and granuloma formation.
- Clinical Presentation:
- Signs and symptoms are nonspecific and vary from an asymptomatic presentation to symptoms during the immediate or late (months or years following surgery) postoperative period.
- Immediate symptoms include pain, discharge or inflammation, and fever.
- Key Diagnostic Features:
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Variety of radiologic patterns depending on the time the foreign body has remained in the surgical site, type of material utilized, anatomic location, and histopathologic features
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For example, in some microfibrillar collagen textilomas, a robust allergic response with prominent eosinophilic infiltrate and foci of degenerating hemostat surrounded by hypercellular cuffs mimics the histologic and MRI appearances of necrosis. The MRI signal intensity depends on the quantity of fluid and protein present in the lesion. Generally, the imaging findings include the following:
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CT: central hypodense lesion with a contrast-enhancing ring
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MRI: centrally hyperintense lesion on T2-weighted MR images surrounded by a rim of hypointensity (capsule); a central wavy or spotted pattern or presence of strips of hyposignal on T2WI compatible with gauze fibers
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Prominent reactive vascular proliferation correlates with the presence of ring enhancement.
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DWI usually shows restriction of water molecules corresponding with high protein contents within the lesion.
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- Differential Diagnoses:
- This pathology must be considered within the differential diagnoses of the immediate and late postoperative surgical complications of different pathologies.
- May present with neuroimaging features that mimic recurrent tumor, abscess, hematoma, and radiation necrosis
- Treatment:
- Surgical resection is the treatment of choice.
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