Lin et al. World Journal of Surgical Oncology 2014, 12:101
http://www.wjso.com/content/12/1/101

WORLD JOURNAL OF
SURGICAL ONCOLOGY

CASE REPORT

Open Access

Surgicel™ application in intracranial hemorrhage
surgery contributed to giant-cell granuloma in a
patient with hypertension: case report and review
of the literature
Bowen Lin1,2, Hongfa Yang1, Mengzhao Cui1, Ye Li3 and Jinlu Yu1*

Abstract
Background: Surgicel™ is an oxidized cellulose preparation that is widely applied in neurosurgery due to its
hemostatic effect and good tissue compatibility. Tumor-like lesions induced by Surgicel® application in cerebral
surgery have been rarely reported, especially for intracranial hemorrhage debridement surgery in patients with
hypertension.
Case presentation: This case report describes a rare case in which Surgicel™ application led to a foreign body
reaction, contributing to the development of an intracranial giant-cell granuloma. A 49-year-old female hypertensive
patient was diagnosed with intracranial hemorrhage. She was treated with debridement surgery that employed
Surgicel™ application. Although a satisfactory hemostatic effect was achieved, the patient was diagnosed with
epilepsy 6 months later. Subsequent magnetic resonance imaging revealed an intracranial space-occupying lesion.
After undergoing en bloc resection of the lesion, the patient was diagnosed with a Surgicel™-related intracranial
giant-cell granuloma by histopathology.
Conclusions: Application of Surgicel™ during intracranial hemorrhage debridement surgery may be associated with
a risk of granuloma development due to formation of a tumor-like space-occupying lesion in the surgery bed. Even
a low risk of tumor development implies a need for caution when applying Surgicel™, especially when solely used
to achieve a hemostatic effect.

Background
In recent years, absorbable hemostatic materials have
emerged as standard tools in neurosurgery. Covering the
neurosurgical bed with hemostatic material helps to prevent hematoma due to wound bleeding. As one of the
most widely applied absorbable hemostatic materials,
Surgicel™ (Ethicon, Inc., a Johnson & Johnson company;
Somerville, NJ) is an oxidized cellulose preparation manufactured by Ethicon Inc. of Johnson & Johnson Medical
Limited. Extensive clinical evidence has shown that the
application of Surgicel™ during cerebral surgery rapidly
promotes blood clotting and effectively controls bleeding.
Moreover, Surgicel™ has been demonstrated to display

superior tissue compatibility compared to other resorbable
hemostatic agents [1-3].
A few cases of Surgicel™-induced foreign body reactions have been reported, all of which involved organs
outside the nervous system; specifically, giant cell granulomas developed in surgical beds of the cardiac, renal,
and adrenal gland tissues [4-6]. To the best of our knowledge, no previous report in the literature has described
Surgicel™-induced tumor-like lesions after hemorrhage
debridement surgery in hypertensive intracerebral hemorrhage. Herein, we describe a case of giant-cell granuloma in the surgical bed following Surgicel™ application
in hemorrhage debridement surgery.

* Correspondence: jinluyu@hotmail.com
1
Department of Neurosurgery, First Hospital of Jilin University, 71 Xinmin
Avenue, Changchun 130021, China
Full list of author information is available at the end of the article

Case presentation
A 49-year-old female with a 5-year history of hypertension was hospitalized for grand mal seizures. Six months

© 2014 Lin et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited.

Lin et al. World Journal of Surgical Oncology 2014, 12:101
http://www.wjso.com/content/12/1/101

prior to hospitalization, the patient had been diagnosed
with right basal ganglia hemorrhage via computed tomography (CT) scan (Figure 1A) and underwent treatment
by hemorrhage debridement and craniotomy decompression surgery. The surgical routine included the application of Surgicel™ to stop bleeding in the surgical
bed. The postoperative recovery was unremarkable, and
the patient was discharged to resume independent living.
Two months after hemorrhage treatment, the patient received a titanium plate to restore the skull structure.
Five months after hemorrhage treatment, the patient
suffered two grand mal seizures, which featured transient loss of consciousness and limb rigidity, with episodes
lasting approximately 5 minutes. Physical examination
upon hospital admission showed left upper limb muscle
strength of grade II, left lower limb muscle strength of
grade IV, and positive left Babinski sign, but no signs of
neurological defect.
Magnetic resonance imaging (MRI) studies showed an
irregularly shaped lesion in the right frontal temporal
lobe and basal ganglia, with a mixed signal (Figure 1B)
including reduced signals in T1WI and T2WI and an

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increased signal indicative of dark fluid. After the signal
was strengthened, the MRI-detected lesion measured
1.7 cm × 3.7 cm (Figure 1C, 1D). Magnetic resonance
spectroscopy (MRS) studies showed a focal signal of
heterogeneous intensity, an unstable spectral baseline in
the lesion due to signal interference of liquid and hemosiderin, and an increased choline (Cho) peak and Cho/
N-acetylaspartate (NAA) ratio. The presence of abnormal gliosis in the right frontotemporal lesion area led to
a diagnosis of suspected tumor (Figure 2).
The space-occupying lesion was surgically resected. The
titanium plate was removed, and the frontotemporal lesion and related dural adhesions were visually identified.
The gross appearance of the lesion included pale coloration, rough surface, poor blood supply, and clear boundaries. The bottom of the lesion was tightly adhered to the
lateral ventricle. Under microscopic guidance, the lesion
was completely resected. The patient’s postoperative recovery was unremarkable. A CT scan 5 days after surgery
showed complete lesion exenteration.
Pathological analysis indicated a foreign body response,
as evidenced by substantial amounts of foam-like cells

A

B

C

D

Figure 1 Images taken before and after surgery. (A) Computed tomography (CT) scan showing a region with high-intensity hemorrhage in the
right basal ganglia. (B) Magnetic resonance imaging (MRI) results showing irregularly shaped lesions in the right frontal temporal lobe and basal
ganglia, with mixed signal and dark fluid with low or higher signal. Lesion size was 1.7 cm × 3.7 cm. (C-D) Lesion observed after strengthening the
signal (arrow).

Lin et al. World Journal of Surgical Oncology 2014, 12:101
http://www.wjso.com/content/12/1/101

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A

B

C

D

Figure 2 Magnetic resonance spectroscopy (MRS) analysis. (A) MRS showed a focally heterogeneous signal intensity and an unstable spectral
baseline in the lesion due to signal interference by the liquid and hemosiderin. (B) Increased choline (Cho) peak and CHO/N-acetylaspartate
(NAA) value were observed. (C-D) MRS of the left side was shown.

distributed throughout the lesion. The presence of gliosis
led to the final diagnosis of a giant-cell granuloma caused
by Surgicel™ application (Figure 3). The patient was
discharged to home 8 days after surgery. There were no
remarkable physical, clinical, or imaging findings at the
6-month follow-up visit.

Discussion
The formation of surgical beds is unavoidable during
neurosurgery, and the normal soft structure of the brain
has insufficient strength to support the new vasculature.
Traditionally, hemostasis had been achieved during surgery by electrical stimulation. However, this method can
cause some vessels to sink into the brain tissue, making
coagulation more difficult, or can liquefy the brain tissue,
causing irreparable injury [7]. The development of absorbable homeostatic materials to cover the surgery bed overcame the risks associated with electrocoagulation, while
effectively achieving control of slight, especially oozing,
bleeding. The currently available absorbable homeostatic

materials, including gelatin sponge, Surgicel™, and microfiber collagen, are considered suitable for clinical application due to their observed tissue compatibility.
Surgicel™ is an oxidized cellulose polymer, with polyglucuronic glucuronide as its effective functional unit.
Blood absorption initiates within 1 day after its application, but complete absorption requires 4 to 8 weeks [8].
Compared to other hemostatic substances, Surgicel™ has
an especially high level of tissue compatibility; however,
occasional cases of foreign body reactions, such as abscesses, inflammation, and giant-cell granuloma, have
been reported with its use [4-6,9,10]. Interestingly, in
each case of Surgicel™-induced giant-cell granuloma, the
granuloma was initially misdiagnosed as a tumor. For
example, Tefik et al. reported a case of Surgicel™-related
granuloma in a laparoscopic kidney tumor resection
surgery that was misdiagnosed as tumor recurrence
[9]. Gao et al. [10] reported a case of Surgicel™-related
granuloma that was misdiagnosed as a tumor 1 month
after hysterectomy and right oophorectomy. These

Lin et al. World Journal of Surgical Oncology 2014, 12:101
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A

B

C

Figure 3 Histopathologic analysis of resected specimen. (A) Foreign body and giant cell reaction (left); gliosis (right) (magnification: ×200).
(B) Foreign body and foam-like cells assembled in the lesion tissue (magnification: ×400). (C) Gliosis observed in the lesion (magnification: ×400).

previous cases of granuloma formation in organs outside the nervous system were ultimately found to be due
to chronic inflammatory reactions. Overactivated giant
cells assembled around the Surgicel™, forming the
chronic giant-cell granuloma [11].
A similar immune-related mechanism may have contributed, at least in part, to the Surgicel™-related granuloma observed in the brain of our patient. However, a
Surgicel™-related granuloma in the brain will have distinctive features from those involving other organs because the blood–brain barrier functions to prohibit giant
cell infiltration and assembly in the brain [12]. To address this issue, we reviewed the clinical characteristics
of the previously reported Surgicel™-related granulomas,
and compared them to those of the granuloma in our
patient.
Sandhu et al. reported that the clinical manifestations
of two Surgicel™-related granulomas occurring after
brain tumor resection were similar to those of other
intracranial space-occupying lesions [13]. The time to
granuloma formation after Surgicel™ application in organs outside the nervous system ranges from 1 to 36
months [10]. The two Surgicel™-related granulomas in
brain reported by Sandhu et al. formed within 1 and 3
months after surgery, respectively. In contrast, Ito et al.
reported three cases of Surgicel™-related granuloma formation in brain that occurred within the time span of 13
to 21 months [14]. Hence, the few reported cases of

Surgicel™-related granuloma in brain appear to have
formed within the same timeline as Surgicel™-related
granulomas in other organs outside the nervous system.
Consistent with this finding, the Surgicel™-related granuloma case presented herein formed 6 months after surgery for cerebral hemorrhage.
Another intriguing feature of Surgicel™-related granulomas is the fact that they are commonly misdiagnosed
as brain tumors, particularly in cases of granuloma forming after cerebral tumor resection. In two previous
cases, the Surgicel™-related granuloma manifested as a
space-occupying lesion with heterogeneous density by
CT scan [13,14] and mixed-signal with surrounding
edema by MRI [15]. Such imaging features do not facilitate the ability to distinguish a granuloma from a brain
tumor, increasing the risk of misdiagnosis. For our patient, MRS was used for further investigation of the
lesion and helped to identify the granuloma as a tumor.
To confirm the MRS-based tumor diagnosis, histopathologic analysis of the resected lesion was performed.
Hematoxylin-eosin (HE) staining of the unabsorbed Surgicel™ substance showed mild eosinophil infiltration (indicated by blue or lavender coloration). Because the blood
clot around the unabsorbed Surgicel™ was gradually
absorbed, the Surgicel™ was left in place. The blood clot
appeared in the HE-stained lesion sections as a ‘ghostly’
fiber surrounding the Surgicel™ substance, and no tissue
accumulation was observed surrounding the Surgicel™.

Lin et al. World Journal of Surgical Oncology 2014, 12:101
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Notably, numerous multinucleated giant cells were found
around these fibers [2]. The pathological hallmarks of this
case were consistent with the features of granuloma.
Hence, the case was diagnosed as Surgicel™-elicited granuloma. Although the features of Surgicel™-related granuloma are not distinguishable from those of tumor, this
case indicates that a tumor-like space-occupying lesion
that forms in the surgery bed after Surgicel™ application
during non-tumor surgery may have a high risk of becoming a Surgicel™-related granuloma.

Conclusions
Although low, the risk of developing Surgicel™-related
granuloma after surgery indicates a need for caution in
applying Surgicel™, especially when it is used solely for
the purpose of achieving a hemostatic effect. However,
the risk of granuloma may be reduced by removing the
unabsorbed Surgicel™ after the hemostatic effect has
been achieved, or by reducing the amount of Surgicel™
applied. When a tumor-like space-occupying lesion is
observed in the intracranial surgery bed after surgery
employing Surgicel, the rare possibility of Surgicel™related granuloma should be considered.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying images. Copies of the written consent are available for review upon request.
Abbreviations
Cho: choline; CT: computed tomography; HE: hematoxylin-eosin;
MRI: magntic resonance imaging; MRS: magnetic resonance spectroscopy;
NAA: N-acetylaspartate.

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doi:10.1186/1477-7819-12-101
Cite this article as: Lin et al.: Surgicel™ application in intracranial
hemorrhage surgery contributed to giant-cell granuloma in a patient
with hypertension: case report and review of the literature. World Journal
of Surgical Oncology 2014 12:101.

Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
LBW wrote the initial draft. LBW and YHF contributed equally to this work.
YJL is the surgeon. All authors read and approved the final manuscript.
Acknowledgements
The authors thank Medjaden Bioscience for assisting in the preparation of
this paper.
Author details
1
Department of Neurosurgery, First Hospital of Jilin University, 71 Xinmin
Avenue, Changchun 130021, China. 2Department of Neurosurgery, Jilin
Central Hospital, 4 Nanjing Avenue, Jilin, Nanjing 130012, PR China.
3
Department of Radiology, First Hospital of Jilin University, 71 Xinmin
Avenue, Changchun 130021, China.
Received: 23 June 2013 Accepted: 7 April 2014
Published: 21 April 2014
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