Nodule on the vertex of the scalp

Presenter: Stephen Hemperly, DO
Dermatology Program: Lehigh Valley Health Network
Program Director: Stephen M. Purcell, DO
Submitted on: Feb 18, 2015

CHIEF COMPLAINT:  Our patient is a 71 year-old Caucasian male who presented with a one-year history of a nodule on the vertex of the scalp.

CLINICAL HISTORY:

Signs and symptoms:  The lesion had become soft and tender during the week prior to presentation. He admitted to headaches and a buzzing sound in his head. He denied all other neurologic symptoms.

Previous Treatment:  The patient was given amoxicillin from a primary care physician and was referred to us for excision of a presumed inflamed cyst.

Other information:  Upon superficial incision, there was more bleeding than would be expected for a scalp, and the procedure was immediately discontinued. Hemostasis was obtained and the patient was sent for an ultrasound of the lesion.
Medical History/Surgical History: Intracranial arteriovenous fistula treated in 2013, two substantial falls in childhood with head trauma and loss of consciousness, essential hypertension, aortic aneurysm

PHYSICAL EXAM:

The patient had a 2 cm pink, somewhat rubbery, subcutaneous, non-mobile nodule on the vertex of the scalp (figure 1).

Figure 1: Clinical image of the 2 cm arteriovenous fistula on the vertex of the scalp after the lesion was superficially incised for a biopsy.

LABORATORY TESTS:

An ultrasound demonstrated a “small hypoechoic nodule measuring up to 0.5 cm containing a tangle of vessels in the subcutaneous soft tissue corresponding to the palpable abnormality.” A cerebral angiogram demonstrated a “recurrent dural arteriovenous fistula of the superior sagittal sinus with multifocal supply,” which connected with this scalp nodule (Figure 2).

Figure 2: Cerebral angiogram demonstrating a, “recurrent dural arteriovenous fistula of the superior sagittal sinus with multifocal supply,” which connected with this scalp nodule.

DERMATOHISTOPATHOLOGY:

None

DIFFERENTIAL DIAGNOSIS:

1.   Scalp Arteriovenous Fistula
2.   Inflamed Cyst
3.   Neoplasm


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