Minimizing cotton retention in neurosurgical procedures: Which imaging modality can help?

Raphael Bechtold, Niki Tselepidakis, Benjamin Garlow, Sean Glaister, William Zhu, Renee Liu, Alexandra Szewc, Arushi Tandon, Zachary Buono, James Pitingolo, Cristina Madalo, Isabella Ferrara, Collin Shale, Thomas Benassi, Micah Belzberg, Noah Gorelick, Brian Hwang, Camilo A. Molina, George Coles, Betty TylerIan Suk, Judy Huang, Henry Brem, Amir Manbachi

Research output: Chapter in Book/Report/Conference proceedingConference contributionpeer-review

3 Scopus citations


Cotton balls are used in neurosurgical procedures to assist with hemostasis and improve vision within the operative field. Although the surgeon can reshape pieces of cotton for multiple intraoperative uses, this customizability and scale also places them at perpetual risk of being lost, as blood-soaked cotton balls are visually similar to raw brain tissue. Retained surgical cotton can induce potentially life-threatening immunologic responses, impair postoperative imaging, lead to a textiloma or misdiagnosis, and/or require reoperation. This study investigated three imaging modalities (optical, acoustic, and radiographic) to find the most effective method of identifying foreign bodies during neurosurgery. First, we examined the use of dyes to increase contrast between cotton and surrounding parenchyma (optical approach). Second, we explored the ability to distinguish surgical cotton on or below the tissue surface from brain parenchyma using ultrasound imaging (acoustic approach). Lastly, we analyzed the ability of radiography to differentiate between brain parenchyma and cotton. Our preliminary testing demonstrated that dark-colored cotton is significantly more identifiable than white cotton on the surface level. Additional testing revealed that cotton has noticeable different acoustic characteristics (eg, speed of sound, absorption) from neural tissue, allowing for enhanced contrast in applied ultrasound imaging. Radiography, however, did not present sufficient contrast, demanding further examination. These solutions have the potential to significantly reduce the possibility of intraoperative cotton retention both on and below the surface of the brain, while still providing surgeons with traditional cotton material properties without affecting the surgical workflow.

Original languageEnglish
Title of host publicationMedical Imaging 2020
Subtitle of host publicationBiomedical Applications in Molecular, Structural, and Functional Imaging
EditorsAndrzej Krol, Barjor S. Gimi
ISBN (Electronic)9781510634015
StatePublished - 2020
EventMedical Imaging 2020: Biomedical Applications in Molecular, Structural, and Functional Imaging - Houston, United States
Duration: Feb 18 2020Feb 20 2020

Publication series

NameProgress in Biomedical Optics and Imaging - Proceedings of SPIE
ISSN (Print)1605-7422


ConferenceMedical Imaging 2020: Biomedical Applications in Molecular, Structural, and Functional Imaging
Country/TerritoryUnited States


  • Brain surgery
  • Contrast
  • Cotton balls
  • Detectability
  • Gossypiboma
  • Medical imaging
  • Optics
  • Retained foreign object
  • Textiloma
  • Ultrasound
  • X-ray


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