Abstract
Background. Numerous reports have demonstrated how postoperative intracranial granulomas can often mimic neoplasm clinically, radiologically, and even macroscopically. Herein we present an unusual case of postsurgical intracranial aseptic granuloma secondary to a chronic inflammatory reaction without any identifiable retained foreign body. Case Description. A 71-year-old patient started complaining of severe headache seven months after surgical excision of WHO Grade I right frontal falx meningioma. CT and MRI scans disclosed a contrast-enhanced lesion with diffuse mass effect in the previous surgical site. The lesion was resected; intraoperative finding and histological specimens led to the diagnosis of postoperative granuloma, likely expression of a glial reaction to the fluid absorbable hemostatics applied in the surgical site after meningioma excision. The possible granuloma-inducing materials and the timing of granuloma formation are discussed. Conclusion. A comprehensive analysis of clinical and neuroradiological data, as well as results of blood tests including positive and negative acute phase proteins, is mandatory to raise the suspicion of postoperative granuloma. The treatment options should be evaluated on a case-by-case basis, with a conservative attitude being the one of choice only for patients without progressive neurological deficit. Alternatively, aggressive surgical treatment and histopathological examination should be advocated.
Highlights
Intracranial granulomas are a rare pathologic finding; their formation is expression of chronic inflammation characterized by accumulation of modified macrophages and is initiated by a variety of infectious and noninfectious agents [1]
After a revision of all the clinical and radiological data and supported by the fact that no evidence of foreign body was histologically found into the granuloma, but elements of advanced degradation of the fluid absorbable hemostatics applied in the surgical site after the meningioma excision, we have speculated that this space-occupying mass might likely result as a glial reaction to their intraoperative use
A Medline search of the literature published until December 2011, using subject heading “intracranial postoperative granuloma,” produced only 42 results. Most of these articles describe aseptic foreign body granuloma formation caused by a variety of substances including gel foam [3], surgical swab [4], bone wax [5], cotton pledgets [6, 7], rayon [8], suture [9], oxidized cellulose [10], microfibrillar collagen [11], muslin gauze [12], and polytetrafluoroethylene [13]; some others refer to infectious granulomas secondary to aneurism surgery [14] or gasserian ganglion decompression [15]
Summary
Numerous reports have demonstrated how postoperative intracranial granulomas can often mimic neoplasm clinically, radiologically, and even macroscopically. We present an unusual case of postsurgical intracranial aseptic granuloma secondary to a chronic inflammatory reaction without any identifiable retained foreign body. A 71-year-old patient started complaining of severe headache seven months after surgical excision of WHO Grade I right frontal falx meningioma. The lesion was resected; intraoperative finding and histological specimens led to the diagnosis of postoperative granuloma, likely expression of a glial reaction to the fluid absorbable hemostatics applied in the surgical site after meningioma excision. A comprehensive analysis of clinical and neuroradiological data, as well as results of blood tests including positive and negative acute phase proteins, is mandatory to raise the suspicion of postoperative granuloma. Aggressive surgical treatment and histopathological examination should be advocated
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