Recurrent intracranial anaplastic ependymoma with late-onset giant scalp metastasis

Surgical resection of a rare scalp arteriovenous malformation: a case report

Introduction and importance

Scalp arteriovenous malformations (AVMs) are intricate vascular anomalies with abnormal connections between arteries and veins in the scalp, leading to serious complications and cosmetic concerns. Managing scalp AVMs is particularly complex in young female patients, where both functional and aesthetic outcomes are crucial. This case report highlights the successful treatment of a young woman with a scalp AVM, emphasizing the importance of early diagnosis and a multidisciplinary approach.

Case presentation

A 30-year-old female presented with a pulsatile scalp mass and significant cosmetic concerns. Diagnostic imaging, including ultrasonography, brain CT scan, MRI, and carotid CT angiogram, confirmed a scalp AVM. The patient underwent a comprehensive treatment plan beginning with endovascular embolization to reduce blood flow to the AVM, followed by surgical resection to remove the lesion. Postoperative follow-up showed a marked reduction in symptoms and lesion volume, with no complications observed.

Clinical discussion

Scalp AVMs, though rare, require prompt diagnosis due to the risk of severe complications such as hemorrhage and cosmetic impact. In this case, a combination of ultrasonography, CT, and MRI provided a detailed assessment of the AVM. A multidisciplinary approach, involving interventional radiology and surgical expertise, was crucial for success. Endovascular embolization minimized intraoperative bleeding and simplified surgical resection, leading to significant symptom and cosmetic improvements. Continuous monitoring is essential for long-term success and early detection of recurrences.

Conclusion

This case underscores the effectiveness of a multidisciplinary approach in managing scalp AVMs in young female patients. Early diagnosis through advanced imaging techniques enables timely and targeted intervention. The combined use of endovascular embolization and surgical resection led to significant symptom resolution and aesthetic enhancement. Collaboration among specialists is vital for optimizing outcomes, and ongoing research will further refine treatment strategies, improving the quality of life for patients with scalp AVMs.

Diagnosis and Management of Scalp Metastases: A Review

Scalp metastases (SMs) are particularly noteworthy, representing around 4-7% of cutaneous neoplasms in this region of the body, possibly due to its rich blood supply. Diagnosis of SMs involves a systematic approach encompassing oncologic history, clinical examination, dermoscopy, imaging, and histopathological assessment. Clinical presentations of SM can vary, but dermoscopy reveals unique vascular patterns aiding in diagnosis. Imaging, particularly MRI and CT, and histopathological evaluation are mandatory for definitive diagnosis. Treatment strategies vary depending on tumor characteristics and staging, ranging from surgical excision to systemic therapies like chemotherapy or radiotherapy. Multimodal approaches tailored to individual cases yield optimal outcomes. The diagnostic tools available do not always allow SMs to be diagnosed, and often the lack of knowledge on the part of oncologists in suspecting SMs can delay an early diagnosis. This review provides clinicians with a practical guide for the timely diagnosis and management of SM, emphasizing the importance of a multidisciplinary approach and personalized treatment strategies for improved patient outcomes.

Recurrent intracranial anaplastic ependymoma with late-onset giant scalp metastasis

Key Clinical Message

Ependymomas are primary brain tumors that predominantly affect individuals between 0 and 4 years of age. Although ependymomas have a propensity for recurrence and the potential to spread within the central nervous system through cerebrospinal fluid (resulting in drop metastases), reports of extra-neural metastatic localizations are exceedingly rare in the existing literature. This case report presents a unique and rare instance of recurrent intracranial anaplastic ependymoma with a late-onset giant scalp metastasis.

Abstract

A 55-year-old male patient with a medical history of partial resection of an atypical supratentorial left temporal ependymoma presented with a recurrent anaplastic ependymoma, which had been managed with surgery and radiotherapy. After a 4-year follow-up, the patient developed a subcutaneous mass in the left parietal region of the scalp. A multidisciplinary team of neurosurgeons and plastic surgeons performed a surgical procedure, which included en bloc removal of the scalp lesion, resection of 1 cm of unaffected skin, and craniotomy to address an osteolytic area in the parietal skull bone. Skin autografts were used for reconstruction. Histological examination confirmed metastasis of anaplastic ependymoma in the scalp. After a delay in starting chemotherapy due to concerns related to the COVID-19 pandemic, the patient eventually initiated chemotherapy, leading to disease stability at a short-term follow-up. Scalp metastases from ependymoma are rarely reported in the literature. Management of such cases necessitates aggressive surgical resection, followed by adjuvant chemotherapy and radiotherapy. A multidisciplinary approach is recommended to ensure effective and targeted therapy, with a focus on preserving aesthetics, particularly in pediatric cases.