J Neurosurg 72:292-294, 1990
Foreign-body granuloma as a complication of wrapping and coating an intracranial aneurysm Case report TOSHIHIKO HAISA, M.D., KOREHITO MATSUMIYA, M.D., NORIO YOSHIMASU, M.D., AND NOBUO KURIBAYASHI, M.D. Departments of Neurosurgery and Pathology, Tokyo Kosei Nenkin Hospital, Tokyo, Japan v" A rare case is presented in which a foreign-body granuloma developed at the site of muslin wrapping and Aron Alpha A coating of an internal carotid artery aneurysm. The importance of avoiding the use of muslin, especially close to the optic nerve and chiasm, is emphasized. KEY WORDS
foreign-body granuloma
N aneurysms which cannot be clipped, a combination of muslin wrapping and tissue-adhesive coating is a clinically accepted alternative technique. 9 We report a rare case in which a foreign-body granul o m a developed 1 89years after muslin wrapping and Aron Alpha A coating of an intracranial aneurysm.
I
Case Report This 56-year-old w o m a n had been well until September, 1986, when she experienced a sudden attack of headache, nausea, and vomiting, associated with right ptosis and diplopia. She was referred to our hospital on the day after the ictus. A computerized tomography (CT) scan showed diffuse subarachnoid clots. A diagnosis of subarachnoid hemorrhage was made, and angiograms disclosed a right internal carotid artery (ICA) aneurysm at the junction with the posterior communicating artery (PCoA), a right middle cerebral artery (MCA) aneurysm, and a left ICA-PCoA aneurysm. F r o m the clinical and radiological features the right ICA-PCoA aneurysm was thought to be the site of rupture. On the day of referral, the right ICA-PCoA and M C A aneurysms were clipped without difficulty. The postoperative clinical course was uneventful without any ischemic symptoms. In October, 1986, the left ICA-PCoA aneurysm was treated by wrapping and coating, because at the time of operation clipping of the aneurysmal neck was found to be technically impossible. Muslin was used for wrap292
muslin
9 aneurysm
wrapping
ping, and Aron Alpha A "Sankyo" (an alkyl-alphacyanoacrylate m o n o m e r ) was added for reinforcement. The patient was discharged soon after with no neurological signs other than a right slight ptosis. In April, 1988, she noticed a gradually progressive visual field defect and was hospitalized.
Examination. Results of the patient's clinical laboratory examinations were normal. Neurological examination revealed a right h o m o n y m o u s hemianopsia. Her visual acuity was 0.5 bilaterally. Other neurological findings were normal. A C T scan with contrast enhancement demonstrated a homogeneously enhancing round lesion adjacent to the left optic nerve (Fig. 1). Angiograms showed narrowing of the AI segment of the left anterior cerebral artery and of the distal portion of the left ICA, with no t u m o r stain (Fig. 2). The left ICAPCoA aneurysm was not visible. Operation. In May, 1988, a repeat left frontotemporal craniotomy was carried out. The t u m o r associated with fibrous tissue was present between the left optic nerve and the left ICA, and surrounded them. It was hard and yellowish-gray in color and was firmly attached to the surrounding structures. The mass was subtotally removed. Histological Examination. Microscopic examination of the surgical specimen showed cotton fibers and reactive foreign-body giant cells with few inflammatory changes (Fig. 3). The diagnosis was a foreign-body granuloma which had originated from the muslin. J. Neurosurg. / Volume 72 / February, 1990
Granuloma at site of wrapped and coated aneurysm
FIG. 3. Photomicrograph of the tumor specimen showing cotton fibers and reactive foreign-body giant cells, with few inflammatory changes. H & E, x 200. FIG. 1. Computerized tomography scan with contrast enhancement showing a homogeneously enhancing lesion in the left posteromedial frontal lobe adjacent to the left optic nerve.
Discussion
Postoperative Course. The patient's visual field defect and visual acuity remained the same as before in spite of decompression of the left optic nerve. Optochiasmatic arachnoiditis was thought to be the cause of visual failure, although the condition did not respond to steroid therapy.
Today, clipping of the aneurysmal neck is generally regarded as the best procedure for treatment o f intracranial aneurysms. However, there are some aneurysms that cannot be clipped despite great progress in microsurgical techniques. In cases of unclippable aneurysms, alternative techniques are used including wrapping and/ or coating, ligation, and balloon embolization.
FIG. 2. Left carotid angiograms, anteroposterior (left) and lateral (right) views, showing narrowing of the A~ segment of the left anterior cerebral artery, and of the distal portioh of the left internal carotid artery.
J. Neurosurg. / Volume 72/February, 1990
293
T. Haisa, et al. In 1958, Gillingham 5 described the use of muslin for wrapping an aneurysm. Pool 1~ c o m m e n t e d on the additional usefulness of muslin for hemostasis in intracranial vascular surgery. Previously reported clinicopathological studies seem to indicate that gauze, and not muscle, is a preferable material for wrapping. 3'9'12"14In 1971, Yashon, et al., 16 reported cyanoacrylate encasement of Surgicel-covered aneurysms as a useful technique. In experimental studies, Aron Alpha A was proved to be minimally toxic to neural and vascular tissues; ~7 however, Chou 2 emphasized that this agent was unsafe for clinical use, and advised against using tissue adhesives except in life-threatening situations. There are a few reports of postoperative intracranial granulomas produced by foreign bodies, including shunt material, 6 fragments o f suture material, 4 or remains o f cotton strips/3 Thus, foreign bodies such as cotton are known to be capable o f eliciting a granulomatous tissue response. In our case, a granuloma developed at the site of muslin wrapping and Aron Alpha A coating of an aneurysm. Undoubtedly, the origin was the muslin which had been used for wrapping. Several reports have documented failure of vision after aneurysm operations using muslin close to the optic nerve and chiasm. ~,8-~L~5 Carney and Oatley I reported three cases of visual failure that occurred after muslin wrapping of aneurysms. Repka, et al., ~ described a case in which surgery revealed a sterile abscess with fibrotic tissue involving muslin; the visual failure in that patient improved after removal of the abscess. T o m s a k ~5 added a similar case in which a marked fibrotic reaction around the optic nerves and chiasm was noted at surgery. In such patients, muslin-induced optochiasmatic arachnoiditis should be suspected, 7"8 although ischemia of the anterior visual pathways is a possible etiology. The loss of vision in our patient appears to have been caused by muslin-induced optochiasmatic arachnoiditis associated with granuloma formation, although delayed neurotoxicity of Aron Alpha A might have been another explanation. It is recommended that surgeons abstain from the use of muslin, especially near the optic nerve and chiasm. If muslin is used in the proximity of the optic nerve and chiasm, it is necessary to monitor the patient with ophthalmological examination in view of the possibility of a muslin-produced granuloma as well as of muslin-induced optochiasmatic arachnoiditis.
References 1. Carney PG, Oatley PE: Muslin wrapping of aneurysms and delayed visual failure. A report of three cases. J Clin
294
Neuroophthalmol 3:91-96, 1983 2. Chou SN: Use of cyanoacrylates. J Neurosurg 46:266, 1977 (Letter) 3. Ebina K, Moriyama T, Ohkuma H, et al: [A clinicoexperimental study on the wrapping material for cerebral aneurysm.] Neurol Med Chir 25:455-462, 1985 (Jpn) 4. Epstein AJ, Russell EJ, Berlin L, et al: Suture granuloma: an unusual cause of an enhancing ring lesion in the postoperative brain. J Comput Assist Tomogr 6: 815-817, 1982 5. Gillingham FJ: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coil Surg Engl 23: 89-117, 1958 6. Korosue K, Tamaki N, Matsumoto S, et al: Intracranial granuloma as an unusual complication of subdural peritoneal shunt. Case report. J Neurosurg 55:136-138, 1981 7. Lavin P: Muslin-induced optochiasmatic arachnoiditis? Neurosurgery 20:505, 1987 (Letter) 8. Marcus AO, Demakas J J, Ross HA, et al: Optochiasmatic arachnoiditis with treatment by surgical lysis of adhesions, corticosteroids, and cyclophosphamide: report of a case. Neurosurgery 19:101 - 103, 1986 9. Mount LA, Antunes JL: Results of treatment of intracranial aneurysrns by wrapping and coating. J Neurosurg 42:189-193, 1975 10. Pool JL: Muslin gauze in intracranial vascular surgery. Technical note. J Neurosurg 44:127-128, 1976 11. Repka MX, Miller NR, Penix JO, et al: Optic neuropathy from the use of intracranial muslin. J Clin Neuroophthalmol 4:147-150, 1984 12. Sachs E Jr: The fate of muscle and cotton wrapped about intracranial carotid arteries and aneurysms. A laboratory and clinico-pathological study. Acta Neurochir 26: 121-137, 1972 13. Shimosaka S, Waga S: Foreign-body granuloma simulating recurrence of falx meningioma. Case report. J Nenrosurg 59:1085-1087, 1983 14. Taylor JC, Choudhury AR: Reinforcement with gauze wrapping for ruptured aneurysms of the middle cerebral artery. J Neurosurg 47:828-832, 1977 15. Tomsak RL: Muslin optic neuropathy. J Clin Neuroophthalmol 5:71, 1985 (Letter) 16. Yashon D, White RJ, Arias BA, et al: Cyanoacrylate encasement of intracranial aneurysms. Technical note. J Neurosurg 34:709-713, 1971 17. Yodh SB, Wright RL: Experimental evaluation of four synthetic adhesives for possible treatment of aneurysms. J Neurosurg 26:504-510, 1967
Manuscript received June 1, 1989. Address for Dr. Haisa: Clinique Neuro-Chirurgicale de la Pitir, 75651 Paris 13, France. Address reprint requests to: Norio Yoshimasu, M.D., Department of Neurosurgery, Tokyo Kosei Nenkin Hospital, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo 162, Japan.
J. Neurosurg. / Volume 72/February, 1990
Foreign-body granuloma as a complication of wrapping and coating an intracranial aneurysm Case report TOSHIHIKO HAISA, M.D., KOREHITO MATSUMIYA, M.D., NORIO YOSHIMASU, M.D., AND NOBUO KURIBAYASHI, M.D. Departments of Neurosurgery and Pathology, Tokyo Kosei Nenkin Hospital, Tokyo, Japan v" A rare case is presented in which a foreign-body granuloma developed at the site of muslin wrapping and Aron Alpha A coating of an internal carotid artery aneurysm. The importance of avoiding the use of muslin, especially close to the optic nerve and chiasm, is emphasized. KEY WORDS
foreign-body granuloma
N aneurysms which cannot be clipped, a combination of muslin wrapping and tissue-adhesive coating is a clinically accepted alternative technique. 9 We report a rare case in which a foreign-body granul o m a developed 1 89years after muslin wrapping and Aron Alpha A coating of an intracranial aneurysm.
I
Case Report This 56-year-old w o m a n had been well until September, 1986, when she experienced a sudden attack of headache, nausea, and vomiting, associated with right ptosis and diplopia. She was referred to our hospital on the day after the ictus. A computerized tomography (CT) scan showed diffuse subarachnoid clots. A diagnosis of subarachnoid hemorrhage was made, and angiograms disclosed a right internal carotid artery (ICA) aneurysm at the junction with the posterior communicating artery (PCoA), a right middle cerebral artery (MCA) aneurysm, and a left ICA-PCoA aneurysm. F r o m the clinical and radiological features the right ICA-PCoA aneurysm was thought to be the site of rupture. On the day of referral, the right ICA-PCoA and M C A aneurysms were clipped without difficulty. The postoperative clinical course was uneventful without any ischemic symptoms. In October, 1986, the left ICA-PCoA aneurysm was treated by wrapping and coating, because at the time of operation clipping of the aneurysmal neck was found to be technically impossible. Muslin was used for wrap292
muslin
9 aneurysm
wrapping
ping, and Aron Alpha A "Sankyo" (an alkyl-alphacyanoacrylate m o n o m e r ) was added for reinforcement. The patient was discharged soon after with no neurological signs other than a right slight ptosis. In April, 1988, she noticed a gradually progressive visual field defect and was hospitalized.
Examination. Results of the patient's clinical laboratory examinations were normal. Neurological examination revealed a right h o m o n y m o u s hemianopsia. Her visual acuity was 0.5 bilaterally. Other neurological findings were normal. A C T scan with contrast enhancement demonstrated a homogeneously enhancing round lesion adjacent to the left optic nerve (Fig. 1). Angiograms showed narrowing of the AI segment of the left anterior cerebral artery and of the distal portion of the left ICA, with no t u m o r stain (Fig. 2). The left ICAPCoA aneurysm was not visible. Operation. In May, 1988, a repeat left frontotemporal craniotomy was carried out. The t u m o r associated with fibrous tissue was present between the left optic nerve and the left ICA, and surrounded them. It was hard and yellowish-gray in color and was firmly attached to the surrounding structures. The mass was subtotally removed. Histological Examination. Microscopic examination of the surgical specimen showed cotton fibers and reactive foreign-body giant cells with few inflammatory changes (Fig. 3). The diagnosis was a foreign-body granuloma which had originated from the muslin. J. Neurosurg. / Volume 72 / February, 1990
Granuloma at site of wrapped and coated aneurysm
FIG. 3. Photomicrograph of the tumor specimen showing cotton fibers and reactive foreign-body giant cells, with few inflammatory changes. H & E, x 200. FIG. 1. Computerized tomography scan with contrast enhancement showing a homogeneously enhancing lesion in the left posteromedial frontal lobe adjacent to the left optic nerve.
Discussion
Postoperative Course. The patient's visual field defect and visual acuity remained the same as before in spite of decompression of the left optic nerve. Optochiasmatic arachnoiditis was thought to be the cause of visual failure, although the condition did not respond to steroid therapy.
Today, clipping of the aneurysmal neck is generally regarded as the best procedure for treatment o f intracranial aneurysms. However, there are some aneurysms that cannot be clipped despite great progress in microsurgical techniques. In cases of unclippable aneurysms, alternative techniques are used including wrapping and/ or coating, ligation, and balloon embolization.
FIG. 2. Left carotid angiograms, anteroposterior (left) and lateral (right) views, showing narrowing of the A~ segment of the left anterior cerebral artery, and of the distal portioh of the left internal carotid artery.
J. Neurosurg. / Volume 72/February, 1990
293
T. Haisa, et al. In 1958, Gillingham 5 described the use of muslin for wrapping an aneurysm. Pool 1~ c o m m e n t e d on the additional usefulness of muslin for hemostasis in intracranial vascular surgery. Previously reported clinicopathological studies seem to indicate that gauze, and not muscle, is a preferable material for wrapping. 3'9'12"14In 1971, Yashon, et al., 16 reported cyanoacrylate encasement of Surgicel-covered aneurysms as a useful technique. In experimental studies, Aron Alpha A was proved to be minimally toxic to neural and vascular tissues; ~7 however, Chou 2 emphasized that this agent was unsafe for clinical use, and advised against using tissue adhesives except in life-threatening situations. There are a few reports of postoperative intracranial granulomas produced by foreign bodies, including shunt material, 6 fragments o f suture material, 4 or remains o f cotton strips/3 Thus, foreign bodies such as cotton are known to be capable o f eliciting a granulomatous tissue response. In our case, a granuloma developed at the site of muslin wrapping and Aron Alpha A coating of an aneurysm. Undoubtedly, the origin was the muslin which had been used for wrapping. Several reports have documented failure of vision after aneurysm operations using muslin close to the optic nerve and chiasm. ~,8-~L~5 Carney and Oatley I reported three cases of visual failure that occurred after muslin wrapping of aneurysms. Repka, et al., ~ described a case in which surgery revealed a sterile abscess with fibrotic tissue involving muslin; the visual failure in that patient improved after removal of the abscess. T o m s a k ~5 added a similar case in which a marked fibrotic reaction around the optic nerves and chiasm was noted at surgery. In such patients, muslin-induced optochiasmatic arachnoiditis should be suspected, 7"8 although ischemia of the anterior visual pathways is a possible etiology. The loss of vision in our patient appears to have been caused by muslin-induced optochiasmatic arachnoiditis associated with granuloma formation, although delayed neurotoxicity of Aron Alpha A might have been another explanation. It is recommended that surgeons abstain from the use of muslin, especially near the optic nerve and chiasm. If muslin is used in the proximity of the optic nerve and chiasm, it is necessary to monitor the patient with ophthalmological examination in view of the possibility of a muslin-produced granuloma as well as of muslin-induced optochiasmatic arachnoiditis.
References 1. Carney PG, Oatley PE: Muslin wrapping of aneurysms and delayed visual failure. A report of three cases. J Clin
294
Neuroophthalmol 3:91-96, 1983 2. Chou SN: Use of cyanoacrylates. J Neurosurg 46:266, 1977 (Letter) 3. Ebina K, Moriyama T, Ohkuma H, et al: [A clinicoexperimental study on the wrapping material for cerebral aneurysm.] Neurol Med Chir 25:455-462, 1985 (Jpn) 4. Epstein AJ, Russell EJ, Berlin L, et al: Suture granuloma: an unusual cause of an enhancing ring lesion in the postoperative brain. J Comput Assist Tomogr 6: 815-817, 1982 5. Gillingham FJ: The management of ruptured intracranial aneurysm. Hunterian Lecture. Ann R Coil Surg Engl 23: 89-117, 1958 6. Korosue K, Tamaki N, Matsumoto S, et al: Intracranial granuloma as an unusual complication of subdural peritoneal shunt. Case report. J Neurosurg 55:136-138, 1981 7. Lavin P: Muslin-induced optochiasmatic arachnoiditis? Neurosurgery 20:505, 1987 (Letter) 8. Marcus AO, Demakas J J, Ross HA, et al: Optochiasmatic arachnoiditis with treatment by surgical lysis of adhesions, corticosteroids, and cyclophosphamide: report of a case. Neurosurgery 19:101 - 103, 1986 9. Mount LA, Antunes JL: Results of treatment of intracranial aneurysrns by wrapping and coating. J Neurosurg 42:189-193, 1975 10. Pool JL: Muslin gauze in intracranial vascular surgery. Technical note. J Neurosurg 44:127-128, 1976 11. Repka MX, Miller NR, Penix JO, et al: Optic neuropathy from the use of intracranial muslin. J Clin Neuroophthalmol 4:147-150, 1984 12. Sachs E Jr: The fate of muscle and cotton wrapped about intracranial carotid arteries and aneurysms. A laboratory and clinico-pathological study. Acta Neurochir 26: 121-137, 1972 13. Shimosaka S, Waga S: Foreign-body granuloma simulating recurrence of falx meningioma. Case report. J Nenrosurg 59:1085-1087, 1983 14. Taylor JC, Choudhury AR: Reinforcement with gauze wrapping for ruptured aneurysms of the middle cerebral artery. J Neurosurg 47:828-832, 1977 15. Tomsak RL: Muslin optic neuropathy. J Clin Neuroophthalmol 5:71, 1985 (Letter) 16. Yashon D, White RJ, Arias BA, et al: Cyanoacrylate encasement of intracranial aneurysms. Technical note. J Neurosurg 34:709-713, 1971 17. Yodh SB, Wright RL: Experimental evaluation of four synthetic adhesives for possible treatment of aneurysms. J Neurosurg 26:504-510, 1967
Manuscript received June 1, 1989. Address for Dr. Haisa: Clinique Neuro-Chirurgicale de la Pitir, 75651 Paris 13, France. Address reprint requests to: Norio Yoshimasu, M.D., Department of Neurosurgery, Tokyo Kosei Nenkin Hospital, 5-1, Tsukudo-cho, Shinjuku-ku, Tokyo 162, Japan.
J. Neurosurg. / Volume 72/February, 1990
