
==== Front
Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00722-2
10.1016/j.radcr.2024.07.136
Case Report
Intracranial gossypiboma mimicking a recurrent glioma: A case report
Hannachi Ali MD Hannachi.Ali@live.fr
a⁎
Dkhil Insaf MD a
Jelassi Soumaya MD a
Ghedira Khalil MD b
Bouali Sofiene MD b
Nagi Sonia MD a
a Department of Radiology, National Institute of Neurology of Tunis, Tunis, Tunisia
b Department of Neurosurgery, National Institute of Neurology of Tunis, Tunis, Tunisia
⁎ Corresponding author. Hannachi.Ali@live.fr
13 8 2024
11 2024
13 8 2024
19 11 48494853
4 6 2024
20 7 2024
24 7 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Cranial retained surgical sponges, known as “gossypiboma” or “textiloma”, represent a rare but potentially severe complication following surgical procedures. While it is infrequent, it poses a significant risk, particularly in delicate surgical settings such as neurosurgery. The inadvertent retention of cotton balls or surgical gauzes may cause localized inflammation, infection, abscess, or neurologic sequelae.

In the realm of neurosurgery, where precision is paramount, the occurrence of postoperative brain gossypibomas is particularly concerning.

This case report contributes to the radiological literature by presenting a distinctive instance of postoperative brain gossypiboma. By delving into the radiological intricacies and potential contributing factors to the retention of surgical materials in neurosurgical procedures, our aim is to underscore the significance of a collaborative approach between neurosurgeons and radiologists for enhanced detection and prevention of such complication.

Keywords

Gossypiboma
Textiloma
Brain
Central nervous system
Radiology
Neurosurgery
Postoperative complication
==== Body
pmcIntroduction

“Gossypiboma” or “textiloma” are informal terms used to describe a mass of cotton material inadvertently left behind in a body cavity after surgery. The term “gossypiboma” originates from the Latin word “gossypium,” meaning cotton, and the Swahili word “boma,” which translates to “place of concealment.” Strictly speaking, “gossypiboma” should refer specifically to masses resulting from retained cotton or woven fabrics. The first documented case of a gossypiboma was reported by Wilson in 1884 [1,2].

Case presentation

We report the case of a 14-year-old girl, who presented to the emergency department for progressive headache, nausea, and vomiting over the last few weeks. The neurological examination showed mild ataxia and symptoms of raised intra cranial pressure. She underwent a CT scan of the brain that showed a large rounded mass in the posterior fossa, centered on the cerebellum with hydrocephalus. An MRI study of the brain was then performed on a Siemens 1.5 tesla- scanner that showed a posterior fossa mass containing cystic foci originating from the cerebellum and responsible for obstructive hydrocephalus with transependymal resorption. The mass showed a moderate restricted diffusion. The evoked diagnosis included medulloblastoma and pilocytic astrocytoma (Fig. 1). The tumor was completely removed surgically. Histopathological examination confirmed the diagnosis of pilocytic astrocytoma.Fig. 1 A large midline posterior fossa lesion, centered on the vermis, measuring 39 × 33 × 58 mm. The lesion is hyperintense in T2 and hypointense in T1, with heterogeneous signal and cystic changes. On postcontrast images, there are nodular areas of enhancement. No meningeal enhancement is demonstrated.

Fig 1:

Postoperative MRI-scan revealed a porencephalic cavity and hemorrhagic changes at the posterior fossa. No tumor remnant was found (Fig. 2).Fig. 2 Postoperative brain MRI performed the first day after surgery: there is a postoperative porencephalic cavity communicating with the fourth ventricle, with a hemorrhagic content.

No tumor remnant nor abscess are detected.

Fig 2:

Six months later, the patient presented to the emergency department for headache. She underwent another CT scan that showed intra-ventricular hyperdense mass in the fourth ventricle, that was initially interpreted as intraventricular hematoma (Fig. 3). An MRI of the brain was then performed. It showed a mass at the roof of the fourth ventricle with extension to the floor and to the Sylvius aqueduct measuring 14 × 16 × 27 mm. This lesion was hypointense in T1 and heterogeneous in T1 and FLAIR sequences. There was some hemosiderin deposition in T2* sequence. The lesion demonstrated moderate restricted diffusion and vivid and homogenous enhancement after gadolinium injection (Fig. 4).Fig. 3 Brain CT scan performed 6 months after surgery showing intra ventricular hyperdense lesion in the fourth ventricle suggestive of hematoma.

Fig 3:

Fig. 4 Brain MRI scan showing an intra ventricular lesion (yellow circle), slightly hypointense in T1 and hyperintense in T2 with a peripheral hypointense rim. DWI image shows mild diffusion restriction in the central part of the lesion and a hypointense rim. Post contrast sagittal image shows homogeneous and vivid enhancement of the lesion. Another similar lesion is visible at the level of the foramen magnum (red circle).

Fig 4:

Local recurrence of the tumor was suspected according to MRI findings. The patient underwent surgery. The neurosurgeon eliminated the diagnosis of recurrent tumor and found a textiloma at the level of the fourth ventricle (Fig. 5). Histopathological examination revealed features of a chronic inflammatory lesion with the presence of a of foreign material consistent with a gossypiboma.Fig. 5 Intraoperative view of a gossypiboma at the level of the fourth ventricle.

Fig 5:

Note that the neurosurgeon cuts the compresses into small pieces, so an accurate count of sponges could not be carried out at the end of the first intervention.

Discussion

Textiloma, derived from the word “textile”, along with terms like gossypiboma, gauzoma and muslinoma, are designations for inflammatory pseudo-tumors associated with foreign bodies. These terms specifically describe lesions that develop due to the retention of a cotton matrix left during surgery, accompanied by an inflammatory reaction.

All types of resorbable and nonresorbable agents used during surgery such as cotton gauze, cellulose, gelatin sponges, oxidized cellulose (SurgicelTM), gelfoam wafers, or collagen tissue can lead to the formation of gossypibomas as part of an allergic response.

Most of the textilomas reported in literature were seen after abdomino-pelvic, thoracic and orthopedic surgery with only limited literature available for intracranial textilomas.

In existing literature, only 46 cases of cranial gossypibomas have been documented [3]. Nevertheless, the actual prevalence is believed to be underestimated, considering that some cases might remain unreported due to medicolegal concerns.

The time interval between the surgery and the clinical presentation of brain textiloma ranges from the immediate postoperative period to decades after the intervention.

When evaluating a mass lesion following intracranial surgery, considerations should include the possibility of a textiloma, along with recurrent tumors, radiation necrosis, hematomas and abscesses [3,4].

The MRI characteristics vary based on factors such as the type of the material used during surgery and the timing of the MRI scan. Gossypiboma typically manifest as a well-defined focal lesion, predominantly hypointense on T1. On T2, the signal may range from hyperintense to hypointense, depending on the fluid and protein composition. Typically, textilomas have a peripheral fibrotic capsule that appears hypointense on both T1 and T2 sequences, exhibiting enhancement in postcontrast images [[5], [6], [7]].

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the authors used ChatGPT in order to improve language and readability. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Patient consent

Since the patient was minor (aged 14 years old), the consent of her father, her legal representative was obtained for the publication of her case.

Competing Interests: The authors have no conflicts of interest to declare.

Acknowledgment: No subsidies or grants contributed to this work.
==== Refs
References

1 Lauwers RP Van Hee RH Intraperitoneal gossypibomas: the need to count sponges World J Surg 24 2000 521 527 10787070
2 Manzella A Filho PB Albuquerque E Farias F Kaercher J Imaging of gossypibomas: pictorial review Am J Roentgenol 193 6_supplement 2009 S94 101 déc 19933682
3 Akpinar A Ucler N Ozdemir CO Textiloma (gossypiboma) mimicking recurrent intracranial abscess BMC Res Notes 8 2015 390 26318152
4 Agarwal V Vyas S Ahuja CK Bhatia V Tripathi M Salunke P Intracranial textiloma: imaging features and literature review Indian J Radiol Imaging 31 02 2021 441 444 34556928
5 Akpinar A Ucler N Ozdemir CO Textiloma (gossypiboma) mimicking recurrent intracranial abscess BMC Res Notes 8 1 2015 390 déc 26318152
6 Loh RTS Matys T Allinson KSJ Santarius T Intracranial gossypiboma 9 years after intracranial pressure bolt insertion: illustrative case J Neurosurg Case Lessons 3 8 2022 CASE21479 36130548
7 Peloquin P Vannemreddy PSSV Watkins LM Byrne RW Intracranial cotton ball gossypiboma mimicking recurrent meningioma: report of a case with literature review for intentional and unintentional foreign body granulomas Clin Neurol Neurosurg 114 7 2012 1039 1041 22365334
