Intraventricular Bone Wax as Cause of Recurrent Cerebrospinal Fluid Infection: A Neuroradiologic Pitfall

doi:10.1016/j.wneu.2015.11.030

World Neurosurgery

Volume 88, April 2016, Pages 690.e7-690.e9

https://doi.org/10.1016/j.wneu.2015.11.030 Get rights and content

Background

Persistent or recurrent shunt infections can be secondary to predisposing factors, such as isolated compartments, cerebrospinal fluid leaks, or foreign bodies.

Case Description

A 5-year-old girl experienced several episodes of shunt infections. After careful reevaluation of all neuroradiologic records of the patient, a foreign body in the left frontal horn of the lateral ventricle was suspected. An endoscopic approach was used to identify and remove a small fragment of bone wax.

Conclusions

To our knowledge, this is the first report of intraventricular bone wax causing persistent CSF infection. The diagnosis was difficult because wax resembles air on computed tomography and on magnetic resonance imaging, and so it had been not noticed for months. Only its persistence on several images raised the suspicion of foreign body inside the ventricular system.

Introduction

Infection is the most dreaded complication of ventricular shunts because it puts the patient at increased risk of intellectual impairment and death. Intraventricular foreign body may represent a nidus for infection. Fragments of catheters and bone dust are the most frequent foreign bodies found in the ventricles. We report the case of 5-year-old girl who experienced several episodes of shunt infections. After careful reevaluation of all neuroradiologic records of the patient, a foreign body in the left frontal horn of the lateral ventricle was suspected. Using an endoscopic approach, a small fragment of bone wax was identified and removed. Neuroradiologic diagnosis was very difficult because the small fragment of wax appeared as a black spot on both computed tomography (CT) scan and on magnetic resonance imaging (MRI), mimicking a small air bubble or an ependymal vessel. Only persistence of the spot on several images led us to suspect the presence of a foreign body in the ventricular system.

Section snippets

Case Report

The neurosurgical history of this patient began at age 2 years, when a cerebellar pilocytic astrocytoma was diagnosed at another hospital and removed via a suboccipital approach (November 2012). The postoperative period was complicated by acute onset of hydrocephalus. The patient underwent endoscopic third ventriculostomy via a right frontal burr hole. A ventriculoperitoneal shunt was inserted 1 week later because failure of the endoscopic third ventriculostomy. The patient presented 7 months

Discussion

The main causes of persistent or recurrent shunt infection are CSF leak, the presence of isolated compartments inside the ventricular system (multiloculated hydrocephalus), and the presence of foreign bodies. The diagnosis of intracranial foreign bodies is usually simple because catheters and bone fragments are radiopaque and easily detectable on CT scan. To our knowledge, intraventricular migration of bone wax as a cause of recurrent or persistent shunt infection has never been reported.

Bone

Conclusions

In patients with multiple episodes of shunt infection, clinicians should always search for predisposing factors. Careful review of neuroimaging may identify uncommon causes, such as intraventricular migration of bone wax.

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Citation Excerpt :
Although bone wax has potential and promise for haemostasis application, the related complications may outweigh its benefits. As shown in Fig. 2, a series of complications in surgeries were reported, such as failed bone healing, foreign body reaction, granuloma growth, thrombosis, infection and nerve compression [22–46]. A rat calvarial bone model was used to define the local reactions of bone to bone wax [47].
Bone wax, primarily composed of beeswax and softening agent, is a century-old material used to control bleeding of disrupted bone surfaces by acting as a mechanical barrier to seal the wound. The current bone wax products are commonly packed in easy-to-open foil in the form of sterile sticks or plates, with excellent malleability and smooth consistency, enabling cost-effective and easy handling approach for bleeding control. It has also been reported that the inert nature of bone wax causes complications including foreign body reaction, infection promotion and bone healing inhibition. With the advances in biomaterials and the market boost of bone haemostatic materials, the arena of bone wax substitute research has expanded to a wide spectrum of material formulations and forms. However, the development of substitutes of bone wax for translation is a pivotal yet challenging topic because currently a potential candidate is recommended to be just as simple to use, effective and inexpensive to produce as traditional bone wax but also be absorbable and osteogenic. This review provides an overview of bone wax including its history, clinical applications and associated complication. In addition, emerging substitutes of bone wax and outlooks of future directions including the standardised evaluation methods are also discussed as an effort to catalyse the innovation and translation of bone haemostatic agents in the near future.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Case ReportIntraventricular Bone Wax as Cause of Recurrent Cerebrospinal Fluid Infection: A Neuroradiologic Pitfall

Background

Case Description

Conclusions

Introduction

Section snippets

Case Report

Discussion

Conclusions

Ann Thorac Surg

J Craniomaxillofac Surg

Use of bone wax is related to increased postoperative sternal dehiscence

Kardiochir Torakochirurgia Pol

The use of local agents: bone wax, gelatin, collagen, oxidized cellulose

Eur Spine J

Adverse effects of bone wax in surgery of the orbit

Ophthal Plast Reconstr Surg

Bone wax can cause foreign body granuloma in the medulla oblongata

Br J Neurosurg

Case Report
Intraventricular Bone Wax as Cause of Recurrent Cerebrospinal Fluid Infection: A Neuroradiologic Pitfall