Scalloping Characteristics in a Patient with Extra-Cranial Hemangioma.

Infantile hemangiomas are the most common benign tumors of infancy and childhood with a reported incidence of 4% to 10% in infants. We report of a 9 year-old male child with a history of progressively increasing swelling over the right eyebrow region. The lesion was present since childhood; however, it increased in in size over the previous 3-4 months. The CT scan showed scalloping over the right supra-orbital ridge with an intact bone. The child underwent total excision of the lesion. A characteristic scalloping seen on imaging (depression in the outer or inner table of the skull) can help differentiate lesions of extracranial and intracranial origins.

Dear Editor,

Infantile hemangiomas are the most common benign tumors of infancy and childhood with a reported incidence of 4% to 10% in infants [1]. The majority of them are located in the head and neck region [2]. A 9 year-old male child presented with a history of progressively increasing swelling over the right eyebrow region. The lesion was present since childhood; however, it increased in size over the previous 3–4 months. The lesion was not associated with pain. There was no history of trauma, fever, headache or seizures. There was no history of visual disturbances. Local examination revealed a 3×3 cm, soft, fluctuant swelling over the right eye brow region (Figure 1). The swelling was non-pulsatile and there was no bruit. Skin over the swelling was healthy and there was a palpable depression over the right supra-orbital ridge. The trans-illumination test was negative. The CT scan showed scalloping over the right supra-orbital ridge with an intact bone (Figure 2). An initial diagnosis of calvarial hemangioma was made. Because the parents feared that accidental injury can lead to a rupture of the lesion and as the lesion was growing in size, a decision to excise the lesion was made. The child underwent a total excision of the lesion. Intra-operatively, there was smooth scalloping of the right frontal bone (Figure-3). Histopathology confirmed the diagnosis of infantile hemangioma. The child was in good condition on one-year follow-up.

Figure 1

Clinical photography showing a large lesion over the right supra-orbital region covered by normal and healthy skin.

Figure 2

CT scan of the brain (bone window) showing a hypodense, well-defined extracranial swelling over the right supra-orbital region producing a characteristic “scalloping sign”.

Figure 3

Intra-operative photograph showing a depression in the outer table of the calvaria in the supra-orbital region.

The clinical presentation of infantile hemangioma depends on the age of the child, size of the lesion, its extent and morphological characteristics[1,3,4]. Many of these lesions can proliferate rapidly during early infancy but most of the superficial hemangiomas (80%) achieve maximum growth by 3 months of age [5]. It is reported that discoloration of the skin usually disappears in children aged 5 to 7 years, and skin appears normal in at least 50% of them [6]. Many other congenital and acquired lesions of the scalp and calvarial region (including scalp dermoid, sebaceous cysts, lipomas, hemangiomas, anterior meningoencephalocele, cephalhematoma, subgaleal hematoma, lymphangioma, sinus pericranii and abscess) need to be considered in the differential diagnosis of scalp hemangioma in children [7-11]. Based on clinical presentation and examination, scalp infantile hemangiomas (which are usually soft and non-pulsatile masses) can be differentiated from other lesions [4,12]. Computerized tomography (CT scan) with in the bone window is the most appropriate investigation to see the details of the scalp and calvarial lesions (intra-cranial versus extra-cranial location and extent) and to help decide on subsequent management [8,9,13-15]. A characteristic scalloping on imaging (depression in the outer or inner table of the skull) has been described to differentiate between extracranial and intracranial origin of these lesions (extra-cranial lesions produces depression in the outer table of the skull and intra-cranial lesions produces depression in the inner table of the skull) [8,9,13,15,16]. It has been described that infantile hemangiomas can also produce a similar mass effect on the local skeleton [6] and can create scalloping in the bone giving rise scalloping signs. For smaller calvarial hemangiomas, a conservative approach has been recommended. For larger lesions or the lesions which continue to grow or produce cosmetic deformity, a complete surgical excision (to avoid ulceration and hemorrhage) is recommended [1,6,17-21].