Scalp and calvarial masses of infants and children

Ultrasound as a standalone tool for the management of pediatric calvarial dermoid cysts

PURPOSE

Calvarial dermoid and epidermoid cysts are benign lesions common in pediatric neurosurgery. Diagnosis is primarily clinical, with frequent but inconsistent use of imaging. Dermoids have been shown to possess distinct sonographic features, but ultrasound (US) remains underutilized in their management. The purpose of this study is to investigate the independent reliability of US in managing pediatric calvarial dermoids and distinguishing them from other calvarial lesions.

METHODS

A retrospective review of consecutive patients ≤ 21 years of age with surgically resected calvarial masses between 2017-2024 was performed. Demographic, clinical, and imaging data were analyzed. Pearson chi-squared tests were used for comparison of categorical variables and a binomial linear model was generated controlling for age, lesion tenderness, growth, and suture location.

RESULTS

Fifty-nine patients with 61 lesions (31 in females; median age 13 months) were included. Dermoids were more common in younger patients (median age 12 months), along suture lines, and were less likely to present with tenderness (p < 0.001) or rapid growth (p = 0.003). Ultrasound was used in 83% of cases and was the sole imaging modality in 33%. On multivariate analysis, suture location was a significant positive predictor of a dermoid diagnosis (OR = 8.08, 95% CI = 1.67-44.18), while rapid growth was a significant negative predictor (OR = 0.08, 95% CI = 0.003-0.80).

CONCLUSION

Ultrasound presents a sensitive and reliable method for the evaluation of most pediatric calvarial lesions, especially dermoid cysts, and warrants being part of standard workup. With appropriate patient selection, US obviates the need for additional imaging in pediatric patients.

Pediatric Cranial Vault Lesions: A Tailored Approach According to Bony Involvement

BACKGROUND

Cranial vault lesions are common in children, with dermoid and epidermoid cysts being the most frequent. Management is debated due to their slow growth, but early resection can prevent complications and provide a definitive histological diagnosis, which is sometimes linked to systemic diseases.

METHODS

A retrospective study of children treated surgically for cranial vault tumors from January 2011 to April 2023 was conducted. The data collected included age, gender, symptoms, comorbidities, lesion location, radiological features, surgical techniques, histopathology, and recurrence rates.

RESULTS

Eighty-eight children (mean age: 3.5 years, mean tumor size: 1.21 cm) underwent surgery. The most common locations were the frontal and occipital bones. The main diagnoses were dermoid cysts, myofibroma, and Langerhans cell histiocytosis. Gross total resection was achieved in 64 cases with simple skin incisions. In 13 cases, small cranioplasties with bone cement were used. Craniotomy and cranioplasty with autologous bone grafting were performed for 11 patients with lesions larger than 2 cm and full skull thickness erosion.

CONCLUSIONS

Early resection is recommended for complete removal with minimally invasive surgery and to ensure histological diagnosis. For lesions larger than 2 cm with full skull erosion, cranioplasty with autologous bone is the preferred technique.

Facial Soft Tissue Lesions in Children

Facial soft tissue lesions in children are often classified based on their structure or cellular origin and can be benign or malignant. This review focuses on common facial soft tissue lesions in children, their clinical morphology, natural history, and medical and surgical management, with an emphasis on those considerations unique to soft tissue lesions present at this anatomic site.

A solitary scalp mass as the presenting feature of clear cell sarcoma of the kidney in a pediatric patient

Clear cell sarcoma of the kidney is a rare renal malignancy, accounting for 2%-4% of all pediatric renal tumors. In this case report, we describe a 9-year-old boy with an asymptomatic, solitary mass on the scalp, ultimately found to be metastatic clear cell sarcoma of the kidney. This report reviews indications for imaging scalp masses to facilitate making an accurate diagnosis and treatment planning.

Conventional and advanced MR imaging findings in a cohort of pathology-proven dermoid cysts of the pediatric scalp and skull

BACKGROUND

In the pediatric population, dermoid cysts are among the most frequent lesions of the scalp and skull. Imaging plays a key role in characterizing scalp and skull lesions in order to narrow the differential diagnoses. In general, dermoids are described as heterogeneous T1-/T2-hypo- to hyperintense lesions on magnetic resonance imaging.

METHODS

The goal of this retrospective study is to evaluate the diffusion weighted imaging findings while reviewing the conventional T1-/T2-/T1+C-weighted MR characteristics in a pathology-proven series of 14 dermoids of the pediatric scalp and skull.

RESULTS

In our pediatric cohort (eight boys, six girls, age range 3-95 months), half of the dermoids were homogeneous T1-hypointense and homogeneous T2-hyperintense. We found a mixture of restricted (45.5%) and increased diffusion (54.5%) in dermoids. The vast majority of dermoids (91.7%) showed rim enhancement. Most dermoids (57.1%) were located at the midline and adjacent to one of its sutures.

CONCLUSIONS

This study suggests that dermoids may have more variable imaging appearances than hitherto assumed and are frequently seen in close proximity or adjacent to the anterior fontanelle.

Pediatric Neurosurgery in Primary Care: Masses of the Scalp and Skull in Children

There are a wide variety of scalp and skull lesions that can affect the pediatric population, many of which are first encountered by primary care physicians. The differential consists of a broad range of more common congenital lesions, sequelae of trauma, and vascular anomalies, to very rare neoplastic processes. It is important to understand signs and symptoms that may indicate whether a lesion may be benign versus life threatening, what imaging studies are appropriate and how to interpret them, and when to seek referrals to specialists.

Pediatric Calvarial Tumors: 10 Years of Clinical Experience and Differences From the Literature

ABSTRACT

Very few studies have focused exclusively on pediatric calvarial tumors. These studies have primarily addressed the similarities of the cases with those reported in the literature, as opposed to their distinctive features. In contrast, the present study is the most detailed study conducted in the last 10 years that includes only pediatric calvarial tumors and highlights their differences according to the literature. A total of 31 patients with pediatric calvarial tumor surgically treated in our center between 2010 and 2020 were included in the study. The patients' files were analyzed retrospectively and 17 different preoperative, intraoperative, and postoperative parameters were determined and compared with previous studies. Except for the tumors causing lytic or sclerotic lesions, there was at least one distinguishing aspect of our series in all parameters. Despite the many distinctive features, the consensus in the treatment of calvarial tumors is to perform complete resection of the tumor and, if possible, remove some of the adjacent healthy bone. Considering the age factor, however, closure of the resulting bone defects with cranioplasty to address issues of cosmesis and intracranial pressure is yet another aspect of pediatric calvarial tumors, because pediatric cranioplasty has its own specific complications. Using intraoperative neuronavigation and performing tumor resection alone without additional craniectomy are also methods the authors use to prevent major bone defects.

Heterotopic respiratory mucosa in the scalp overlying abnormal bony island in the skull linked to maternal misoprostol use, literature review and surgical experience

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We present a case of abnormal skin overgrowth over an abnormal bony island in a full tern child after misoprostol use.

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Central vertex lesions can vary from overgrowth and undergrowth or under formation of tissues.

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Careful assessment of any child with skull lesion.

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Management algorithm proposes management steps that we applied in our case and can help manage other cases of scalp lesions in pediatric patients.

Background

Congenital scalp lesions rarely occur in children. These lesions are usually noticed at birth and mostly comprise skin and bone tissue loss in the form of acutis aplasia congenita. The management of these lesions is highly dependent on their location and the affected underlying structures.

Case report

We report the case of a baby girl who was referred to us after a normal full-term delivery and who had an area of an abnormal overgrowth of skin (skin tag) on the vertex of the scalp, with an area of surrounding alopecia. She was otherwise healthy with no noted congenital anomalies. Apart from a prenatal history of attempted abortion using misoprostol, she had no significant history or congenital anomalies. She underwent a CT scan and an MRI. She also underwent an operation to excise the overgrowth and to address the underlying bone tissue anomaly. Histopathology showed respiratory mucosa heterotopia. We report this unusual case that suggests the need for an algorithm to manage such cases, as well as the need to investigate the possibility of misoprostol teratogenicity and a probable link to heterotopia.

Conclusion

Congenital skin lesions on the scalp should be approached in a multidisciplinary manner to guide their treatment.

Dermoid and Epidermoid Cysts of Scalp: Case Series of 234 Consecutive Patients

BACKGROUND

Dermoid and epidermoid cysts are among the most frequent lesions of the scalp in the pediatric population. Optimal management of a suspected dermoid or epidermoid cyst in children is debated: Some authors advocate conservative management on the basis of the benign histology of these entities, while others prefer surgical excision.

OBJECTIVE

Our objective is to demonstrate that excision of dermoid and epidermoid cysts is a safe procedure and that early surgery is effective in preventing potential complications related to cyst growth.

METHODS

We retrospectively collected data on patients who underwent surgery for excision of proven dermoid or epidermoid cysts between January 2006 and October 2017.

RESULTS

In 234 patients, 237 cysts were excised. Mean age at presentation was 26.99 ± 32.7 months; 48.7% of patients were operated on between 1 and 3 years of age, and 32.9% were younger than 1 year of age. Cysts were more frequently located in the frontal bone than in occipital and supraorbital regions. In 36.28% of cases there was no significant cranial impingement, while 21.94% of the cysts eroded through a partial thickness of the cranium, 12.23% were in the full thickness of the skull, and 0.84% had epidural extension. We identified 22 intradiploic cysts. Statistical analysis demonstrated significant association between frontal and pterional localization and bone erosion. Neither major complications nor cyst recurrence were observed.

CONCLUSIONS

Excision of dermoid and epidermoid cysts is a safe procedure for neurosurgeons dealing with this disease, even in young patients. Early resection is recommended due to the potential adverse effects that may occur if these cysts are left untreated.

Primary Eosinophilic Granuloma Invading the Skull Base: Case Report and Critical Review of the Literature

A case of eosinophilic granuloma of the lesser wing of the sphenoid bone is reported. The patient was a 5-year-old white male, with left temporal-frontal headache, left III cranial nerve palsy, left exophthalmos and ptosis caused by an osteolytic lesion of the anterior clinoid process extending to the left optic canal and cavernous sinus. The patient underwent surgical resection of pathologic tissue. Pathologic diagnosis was eosinophilic granuloma of the sphenoid bone. Surgical management, postoperative prognosis and differential diagnosis of eosinophilic granuloma of the skull base are discussed along with a review of the literature.

Solitary Eosinophilic Granuloma of the Calvaria

AIMS AND BACKGROUND

Histiocytosis X is a condition characterized by an abnormal proliferation of histiocytes with a variable granulomatous and inflammatory component; bone involvement is almost always present. The aim of this study was to define the management of solitary eosinophilic granuloma (EG) of the calvaria in adult patients, in relation to the size and site of the lesion.

METHODS

Fourteen patients, ranging in age from 7 to 45 years, with solitary eosinophilic granuloma of the calvaria were surgically treated by craniectomy or curettage and cranioplasty. We subgrouped the lesions into two types: A) lesions localized inside the diploë and/or compressing the cerebral parenchyma below but without dural infiltration; B) lesions with mainly intracranial growth, compressing the cerebral parenchyma and infiltrating the dura. The infiltrated dura mater in type B lesions was replaced with a dural patch. Cranioplasty was performed in lesions with a diameter of 4 cm or more and/or located in aesthetically exposed areas of the skull.

RESULTS

None of the patients died during the study and no local or systemic recurrences were observed during follow-up (min. 3 yrs, max. 8 yrs).

CONCLUSIONS

Surgical treatment of patients with isolated EG of the calvaria not only is simple and quick but also allows histological diagnosis of the osteolytic lesion. These patients do not require further adjuvant treatment. Cranioplasty should be performed when the lesion has a diameter of 4 cm or more, when it is located in aesthetically exposed areas of the skull such as the frontal or temporal bones, or when it produces alterations of the normal skull morphology.

Occipital intraosseous dermoid cyst with restricted diffusion on magnetic resonance imaging in a child

A 4-year-old girl presented repeatedly with a complicated occipital mass, which was erroneously treated as a pyogenic granuloma. Imaging performed before a planned surgical resection detected an underlying intraoccipital dermoid with a sinus tract to the skin surface and extension into the posterior fossa. This case highlights the value of high-resolution computed tomography imaging for depiction of anatomic details and the value of magnetic resonance imaging for differential diagnosis and surgical management. A comprehensive literature review of intraosseous dermoid cyst and detailed discussion of the differential diagnoses are provided.

Considerations in the management of congenital cranial dermoid cysts

OBJECTIVE Congenital dermoid cysts (CDCs) develop from the entrapment of the surface ectoderm along the lines of embryonic fusion and have a capacity to grow. Given this capacity for continual expansion, the timing of removal and anticipation of possible epidural extension is important. METHODS The authors retrospectively reviewed records of patients with the diagnosis of dermoid cyst presenting over a period of 10 years. Baseline characteristics, histological reports, and surgical records were collected and analyzed. Only those patients with histological confirmation of dermoid cyst were included in the study. RESULTS One hundred fifty-nine (64 male and 95 female) patients were studied. The average age at the time of surgery ranged from 1 month to 63 years (mean 3.55 ± 9.58 years, median 11 months). Eighteen (11.3%) CDCs were in the midline anterior fontanelle, 52 (32.7%) were frontozygomatic, 14 (8.8%) occurred along the coronal sutures, and 75 (47.2%) occurred along the lambdoid sutures. In 74 (46.5%) cases the cysts were found to insignificantly erode the cranium, 30 (18.9%) eroded through a partial thickness of the cranium, 47 (29.6%) eroded through the full thickness of the cranium, and 8 (5.0%) eroded through the full thickness of the cranium and demonstrated epidural extension. The study population showed female predominance (n = 95, 59.7%). Although cyst location and patient sex were not found to vary significantly with cranial involvement (p = 0.196 and p = 0.066, respectively), delay in time to surgery did vary significantly (p < 0.00001). CONCLUSIONS Congenital cranial dermoid cysts found in infants and children are best removed early.

Clinical Characteristics of Benign Pediatric Cranial Vault Tumors: Surgical Considerations Based on 100 Cases

BACKGROUND/AIMS

Tumors of the cranial vault occur at every age of childhood. Although they are mostly benign lesions, their symptomatology is variable and requires extended diagnostics. The choice of therapeutic strategy strongly depends on histopathological diagnosis, and therefore surgical excision is the elective treatment in such cases. Despite several published papers, the literature still lacks reliable clinical characteristics regarding this heterogeneous group of lesions in pediatric patients.

METHODS

We present a series of 100 children (55 male, 45 female) with scalp and cranial vault masses (average age: 3.6 years; range: 1 month to 17 years). Eighty-three (83%) patients underwent surgical excision. Demographic data, clinical presentation, diagnostic studies, choice of therapy, and the results of treatment were evaluated.

RESULTS

All removed tumors were benign pathologies: pilar cysts (30%), epidermoid/dermoid cysts (21%), vascular malformations (11%), inflammatory tumors (5%), and dysraphic remnants (2%). However, underlying bone destruction was observed in 61% of cases. Cranial extension occurred in 34%. Recurrence was noted in 1 case.

CONCLUSIONS

Cranial vault tumors are characterized by constant growth and may penetrate the cranial cavity. Delayed surgery increases the risk of intracranial complications. Surgical problems include inappropriate planning, higher risk of intraoperative bleeding, and the need for subsequent cranioplasty.

Atretic cephaloceles: a comprehensive analysis of historical cohort

PURPOSE

This study aims to analyze the historical cohort of patients with atretic cephaloceles (ACs) comprehensively, since the literature regarding ACs is limited by small case series or case reports and to report a new venous anomaly concomitant with a parietal AC in our exemplary case.

METHODS

After a PubMed/Medline search with "atretic cephalocele" in April 2016, we retrieved 42 articles, 41 of which were relevant with the topic. Full texts of accessible articles and abstracts of inaccessible articles were read comprehensively. References of retrieved articles were manually searched. Additional 29 articles reporting the cases of atretic, rudimentary, occult, or sequestered cephaloceles were accessed, since these terms have been used interchangeably in the literature.

RESULTS

Median age and mean age of the patients were 1 and 6.69 years, respectively. Female/male ratio was 1.03:1. Atretic cephaloceles were located in different regions, in decreasing order of frequency: parietal (55 %; n = 105), occipital (37 %; n = 71), parieto-occipital (n = 8), frontal (n = 4), asterion (n = 1), and sincipital (n = 1). Concomitant central nervous system (CNS) anomalies were present in 73.3 % of patients with parietal atretic cephaloceles and in 32.4 % of patients with occipital atretic cephaloceles (p < 0.0001). We realized that all patients with worse outcomes had concomitant CNS anomalies (100 %), whereas only 48 % of those with good clinical outcomes had concomitant anomalies (p = 0.0248).

CONCLUSIONS

Atretic cephaloceles present as nodular extrusions on the parietal and occipital regions. Concomitant CNS anomalies, which impair the clinical outcomes, are more common in patients with parietal ACs. Observation-only approach is enough in patients with asymptomatic ACs. However, life-long follow-ups are required, because of recurrence after the surgery.

Eosinophilic granuloma of the occipital bone in an adult: a case report

Eosinophilic granuloma (EG) refers to the most common and benign form of the disorder known as Langerhans' cell histiocytosis. The disease is typically found in children and adolescents and rarely affects adults. We present a case of EG in the occipital bone in a 36-year-old man, who visited our hospital with the chief complaint of left occipital palpable tumor mass with local tenderness and pain for one month. An X-ray of the skull revealed a rounded osteolytic lesion. A computed tomography scan revealed a shadow of soft tissues in the left occipital site involving the entire thickness of the calvaria, which was indicative of marked destruction of the bone. The soft mass was successfully removed. The margins of the skull lesion were excised, and cranioplasty was performed simultaneously with bone cement. A definitive diagnosis of EG was made by histopathology and immunohistochemical detection of S-100 antigen in the tissue samples. With respect to management, we believe surgery is the best option for most accessible cranial lesions of EG. A cranioplasty with bone cement or autologous bone can be performed in the same session to repair the cranial defect.

Primary pediatric skull tumors

BACKGROUND/AIMS

To review the pathological distribution of pediatric primary skull tumors, and to determine the diagnostic value of lesion location, patient age and lesion size.

METHODS

A retrospective chart review identified 51 consecutive pediatric patients with 54 primary skull tumors, treated between 2005 and 2010.

RESULTS

The most common diagnoses were dermoid cysts (n = 34) and fibrous dysplasia (n = 5). While dermoid tumors could reside anywhere (sensitivity = 0.41), a midline lesion had a specificity of 0.9 and a positive predictive value of 0.88. All of the fibrous dysplasia lesions were laterally placed, with a negative predictive value (NPV) of 1. Patient age < or >5 years had a high sensitivity and NPV for dermoid cysts and fibrous dysplasia, respectively. Size appeared to be sensitive (0.91, 0.8), but not specific (0.6, 0.78), with good NPV (0.8, 0.97) when considering dermoid cysts (≤2 cm) or fibrous dysplasia (>2 cm), respectively.

CONCLUSION

Dermoid cysts followed by fibrous dysplasia are the most common primary skull tumors. Lesion location, patient age and lesion size give important clues as to the diagnosis. For the majority of cases, a clinical diagnosis based on CT is sufficient for presurgical evaluation.

Giant intradiploic epidermoid cyst of occipital bone. A case report and literature review

Intradiploic epidermoid cysts are congenital benign lesions. They commonly occur intracranially. Intradiploic epidermoid cyst of the calvarium is very rare and few cases have been reported to date. We describe a giant intradiploic epidermoid cyst of the occipital bone with CT and MRI characteristics including DW imaging and ADC values.

Imaging of the calvarium

The skull vault consists of a multitude of flat bones held together by the cranial sutures. Radiologists encounter a vast array of calvarial pathologies that tend to cause abnormalities in thickness, abnormalities in density, focal defects, or an excess of soft tissue or bone tissue. Further anomalies related to the cranial sutures and fontanelles occur in the dynamic pediatric skull. The imaging features of the host of conditions resulting in these commonly detected calvarial abnormalities are reviewed and illustrated.

Calvarial dermoids and epidermoids in infants and children: sonographic spectrum and follow-up

OBJECTIVE

Dermoids and epidermoids are defined as ectodermal inclusion cysts. The aim of this study was to evaluate the spontaneous natural behavior and the ultrasonographic appearance of calvarial dermoids and epidermoids.

MATERIALS AND METHODS

The ultrasonographic image datasets of 100 consecutive children up to 4 years of age (52 females, 48 males; age range at first examination 1 week to 40 months, mean age 8.3 +/- 6.9 months) presenting with a firm palpable calvarial mass (103 lesions) were studied retrospectively. All ultrasound (US) examinations were performed using a 7- to 10-MHz linear transducer including B-mode and color Doppler sonography. US follow-up studies (up to 47 months) could be achieved in 30 patients with 33 lesions.

RESULTS

At first presentation, all 103 lesions demonstrated very similar US features: a round or oval configuration (diameter 3-18 mm), hypoechogenic, and homogeneous internal structures with a marked hyperechogenic superficial capsule, which were localized adjacent to or expanded into the osseous external calvarial table. No conspicuous flow signs on color Doppler were seen. In 33 lesions with US follow-up investigations, 49% showed variable signs of regression: reduction of size, increase of internal echogenicity, and decrease of demarcation. Eight lesions (24%) remained unchanged. A slight progression up to a maximum diameter of 17 mm but without any increase in osseous destruction was observed in the remainder (27%). There was no lesion with a complete destruction of the underlying bone and no intracranial extension in any of the cases.

CONCLUSIONS

Calvarial dermoids and epidermoids in infants and children show a benign natural behavior with spontaneous regression in a large number of cases. On US, they demonstrate uniform pathognomonic features enabling the correct diagnosis in any of those lesions. Thus, additional, mainly radiation burdening and sometimes misleading imaging techniques should be restricted. Surgical treatment protocols should be handled conservatively and lesions should be primarily followed-up clinically and by US.

A study of 77 cases of surgically excised scalp and skull masses in pediatric patients

OBJECTIVES

Most cases of pediatric scalp and skull masses are either congenital or developmental tumors or diseases, and in many patients, these lesions are accompanied by intracranial extension. Past studies pertaining to these conditions are few, and thus clinical information is as yet inadequate.

MATERIALS AND METHODS

The authors present 75 pediatric patients with 77 cases of surgically treated scalp and skull masses. The most common pathologic condition was Langerhans cell histiocytosis, followed by epidermal cysts, epidermoid and dermoids, scalp hemangiomas, and neurofibromas, in descending order. Intracranial extension was observed in three cases (4%); two cases were malignant tumors that were skull metastasis of a neuroblastoma and a lymphoma, and one case was encephalocele. Lesions followed up because of possible recurrence were 15 cases of Langerhans cell histiocytosis, eight cases of epidermoid and dermoids, two cases of malignant tumors, and one case each of desmoplastic fibroma, myxoma, fibroid dysplasia, and neurofibroma, totaling 29 cases (39%).

CONCLUSION

Although the overall incidence of intracranial extension of pediatric scalp and skull masses is very low and the presence of a malignant tumor or metastatic tumor presenting as a scalp and skull mass is rare, such masses enlarge as time progresses, and there exists a possibility of recurrent disease. Therefore, it is suggested that early surgical resection will afford favorable prognosis for the patients, and meticulous follow-up is necessary in some conditions.

Primary intra-diploic meningioma in a child

BACKGROUND

Primary intra-diploic meningiomas are uncommon in childhood and, at the clinical onset, may be confused with other and more frequent bone tumours because they lack specific clinical and radiological characteristics. Surgery is indicated not only to remove the lesion but also to obtain an accurate histological diagnosis.

CASE REPORT

We report the case of a young girl who presented with a recently developed subcutaneous hard mass in the left pterional region. Neuroradiological investigations revealed an intra-osseous lytic mass with a sclerotic reaction. Diagnosis was possible only after the total removal of the tumour and its histological examination.

Primary Skull Lesions in the Pediatric Population: A 25-Year Experience

Context.—Primary skull lesions are rare in the pediatric population. The differential diagnosis of these lesions is broad and includes both congenital and acquired lesions. Previous studies of skull lesions in the pediatric population suggest that dermoid/epidermoid tumors are the most common childhood skull tumors.

Objective.—To review the clinicopathologic features of primary skull lesions identified within the pediatric population of an academic tertiary medical center.

Design.—A retrospective review of surgical pathology reports during a 25-year period identified 19 primary skull lesions occurring in the pediatric population. Lesions were excluded if they were of known soft tissue or intracranial origin with secondary calvarial involvement, or if they represented a metastasis from a known primary malignancy.

Results.—Nineteen primary skull lesions were identified in 11 male (58%) and 8 female (42%) patients, with a median age at diagnosis of 9.5 years. These lesions were usually benign and most commonly presented as a painless mass (n = 8). The lesions were located in the occipital bone (n = 7), frontal bone (n = 5), parietal bone (n = 2), and temporal bone (n = 1). Diagnoses included epidermoid/ dermoid cyst (n = 8), Langerhans cell histiocytosis (n = 6), intraosseous hemangioma (n = 2), osteoblastoma (n = 1), infantile myofibroma (n = 1), and fibroma (n = 1). Intracranial extension was identified in 1 case, and recurrence was found in only 2 cases.

Conclusions.—Epidermoid/dermoid cysts and Langerhans cell histiocytosis are the most commonly encountered skull lesions in the pediatric population at our institution. Intracranial extension of these lesions is rare, and recurrence is uncommon following complete surgical resection.

Lumps and bumps in neonates and infants

There are many developmental abnormalities that may appear in the neonate and in infants when critical steps in embryogenesis fail. These steps are often not fatal but can lead to significant morbidity for those patients affected. A logical approach is needed in addressing both the diagnostic and therapeutic issues that arise when caring for these patients, as various lesions will warrant an observational approach, and others may require imaging studies or definitive surgical intervention. Additionally, there are other "lumps and bumps" that are seen in the neonatal and infantile age groups that include malignancies and cutaneous neoplasms with associated systemic sequelae.

Vascular stains and hair collar sign associated with congenital anomalies of the scalp

We reported a series of three meningothelial hamartomas, one benign fibrous tumor, and one aplasia cutis congenita presenting with the hair collar sign and a coexistent vascular stain. Our series highlighted the importance of coexisting cutaneous markers found in the newborn period. The presence of a vascular stain and hair collar sign with or without a congenital scalp nodule should increase suspicion of an associated cranial dysraphism.

Heterotopic Neural Nodules of the Scalp

Congenital lesions of the scalp must be approached with caution because of the possibility of intracranial extension. Heterotopic neural nodules, a type of neuroectodermal malformation, are particularly dangerous. They manifest in the newborn as a small lump, are often confused with dermoid cysts, and may have a rudimentary stalk that communicates intracranially. The authors retrospectively reviewed the demographic, clinical, and histopathologic records of 11 infants with 12 heterotopic neural nodules of the scalp seen over the previous two decades. All lesions were located in the parietal or occipital region. All but one patient had an overlying area of alopecia surrounded by a ring of long, coarse hair (the "hair collar sign"), and nine of 11 children had a capillary stain surrounding the lesion. Preoperative imaging correctly identified calvarial defects in five patients. Excision was performed at an average age of 8.6 months. Histopathologic examination showed that nine lesions (nine patients) were heterotopic leptomeningeal tissue and three lesions (two patients) contained glial tissue. Heterotopic neural nodules of the scalp are rare congenital lesions with recognizable clinical and histologic features. Preoperative imaging is essential to document possible intracranial involvement and thus minimize possible penetration of the dura during resection.

Dural enhancement with primary calvarial lesions

The purpose of this study was to relate the pathological and imaging features of dural enhancement and meningeal sign ("dural tail") on contrast-enhanced T1-weighted magnetic resonance (MR) images from patients with primary calvarial lesions as well to assess the accuracy of MR imaging in predicting dural invasion. Thirty-two calvarial tumors studied with contrast-enhanced MR imaging and histopathological examination of the dural specimens were reviewed. Sixteen patients presented dural enhancement, eight with tumor invasion. Tumoral invasion of the dura was observed in one case without enhancement. Malignant lesions showed enhanced dura more commonly than benign lesions (P=0.02). Nodular and discontinuous dural enhancement was statistically associated with dural invasion (P=0.05). Dural tail did not show a specific pathological association. Meningeal enhancement is a nonspecific reaction to calvarial lesions unless nodular and discontinuous. False-negative and -positive cases of dural invasion imply some limitation of contrast-enhanced MR imaging in predicting dural invasion by calvarial neoplasms.

Surgical Treatment of Ossified Cephalhematoma

Cephalhematoma is a collection of blood beneath the periosteum of the bones in the cranial vault. The treatment strategy of most cephalhematoma is conservative. However, in cases of ossified cephalhematoma causing deformities of skull, surgical management is indicated. From 1996 to 2002, the authors treated three cases of ossified cephalhematoma with the suggested pathogenesis of ossification, which cephalhematoma goes to ossification process, rather than calcification. Surgical treatment, which is bony shaving with a burr on the irregular margin site, was performed in one case in which the thickness of the skull in the bulging area was the same as in the normal area in preoperative computed tomography (CT) scan, and a depression did not exist in the operative field. In two cases in which there was any difference in bony density in the preoperative CT scan and depression after removal of cephalhematoma, the bony cap was remodeled into multiple pieces and the depressed region was reconstructed with a remodeled bone cap as an onlay bone graft. There was no evidence of complications and recurrence, and there was good reconstitution of the skull contour in all cases.

Calvarial masses of infants and children. A radiological approach

Children frequently present with asymptomatic head lumps that have been discovered by their parents or by their hairdressers. Other children present with painful lumps or symptoms of intra-cranial masses with calvarial involvement. Imaging plays an important role in the diagnosis of such masses and in subsequent surgical planning. We present a review of the types of lesion that may present in these ways.

Recognizing neurosurgical conditions in the pediatrician's office

Clinical problems with potential neurosurgical ramifications, such as headache and abnormalities of head size and shape, arise often in general pediatric practice. Other neurosurgical issues may manifest themselves less frequently and more insidiously. In either case the pediatrician who is alert to spectrum of the presentations of neurosurgical conditions will direct investigations and referrals efficiently and inspire the confidence of the patient and the family.

Diagnóstico de las lesiones de la calota. Selección de variables por redes neuronales y regresión logística

OBJECTIVES

To establish the minimun set of features needed in the diagnosis of calvarial lesions using computed tomography (CT) and to assess the accuracy of logistic regression (LR) and artificial neural networks (NN) for their diagnosis.

MATERIAL AND METHODS

167 patients with calvarial lesions as the only known disease were enrolled. The clinical and CT data were used for LR and NN models. Both models were tested with the jacknife method. The final results of each model were compared using the area under ROC curves (A 2 ).

RESULTS

The lesions were 73.1 % benign and 26.9% malignant. There was no statistically significant difference between LR and NN in differentiating malignancy. In characterizing the histologic diagnoses, NN was statistically superior to LR. Important NN features needed for malignancy classification were age and edge definition, and for the histologic diagnoses matrix, marginal sclerosis and age.

CONCLUSIONS

A minimum four features is needed to diagnose these lesions, not being important patients' symptoms. NNs offer wide possibilities over statistics for the calvarial lesions study besides a superior diagnostic performance.

Multiple palisading granulomas in the scalp of an infant: a case report

BACKGROUND

We describe an unusual lesion that represents an uncommon but important element in the differential diagnosis of subcutaneous scalp nodules in a child.

CASE DESCRIPTION

A 1-year-old boy presented with two clusters of subcutaneous scalp nodules. The lesions increased in size and number. Computed tomography showed no changes in underlying bone. Findings on magnetic resonance imaging were nonspecific. Serologic and clinical evaluation showed no evidence of rheumatic disease. Complete excision of the nodules, together with adjacent fascia and galea, was performed. Histopathologic examination showed the lesions to be palisading granulomas; given the absence of rheumatic disease, these represented deep granuloma annulare, a benign condition. No recurrence has been observed in our patient.

CONCLUSION

While we chose total excision because of preoperative concerns about a possible malignant tumor, some other authors have suggested that surgery be limited to confirmatory biopsy when a benign lesion such as palisading granuloma is strongly suspected.

Focal calvarial bone lesions. Comparison of logistic regression and neural network models

RATIONALE AND OBJECTIVES

To assess the accuracy of logistic regression (LR) and artificial neural networks (NN) in the diagnosis of calvarial lesions using computed tomography (CT) and to establish the importance of the different features needed for the diagnosis.

METHODS

One hundred sixty-seven patients with calvarial lesions as the only known disease were enrolled. The clinical and CT data were used for LR and NN models. Both models were tested with the leave-one-out method. The final results of each model were compared using the area under receiver operating characteristic curves (Az).

RESULTS

Of the lesions, 73.1%, were benign and 26.9% were malignant. There was no statistically significant difference between LR and NN in differentiating malignancy. In characterizing the histologic diagnoses, NN was statistically superior to LR. Important NN features needed for malignancy classification were age and edge definition, and for the histologic diagnoses matrix, marginal sclerosis, and age.

CONCLUSION

NNs offer wide possibilities over statistics for the study of calvarial lesions other than their superior diagnostic performance.

Extradural dermoid tumours of the posterior fossa

Dermoid tumours in children usually occur in two locations: at the anterior fontanelle and on the occipital squama. An exceptional site of origin for a posterior fossa dermoid cyst is the extradural space. There are only six previous cases of this situation reported in the literature. A series of 103 subscalp and calvarial masses in children were reviewed and three children are reported with extradural dermoids of the posterior fossa, which communicated with the skin through midline occipital dermal sinuses. All three children were seen after the rapid growth or the formation of an abscess in a previously noted occipital subcutaneous mass present since birth. Although computed tomography or magnetic resonance imaging showed the dermal sinus and the intracranial tumour, these studies were unable to ascertain the intradural or extradural nature of the tumours, their exact origin only being established at operation. Histopathological study showed preclinical signs of infection in the two patients that had not yet formed an abscess. It is suggested that early neurosurgical treatment of these neoplasms should be done to prevent the development of severe intracranial infection. The previously reported simplicity of surgical removal of occipital extradural dermoids was not confirmed in this series.

Eikenella corrodens skull infection: a case report with review of the literature

BACKGROUND

Subgaleal abscesses and skull osteomyelitis are very uncommon since the introduction of antibiotics. Eikenella corrodens infection is extremely rare in childhood and has never been reported in calvarial osteomyelitis.

METHODS

We present a previously healthy 9-year-old boy, with a history of frontal contusion without injury, who developed E corrodens osteomyelitis of the skull. The radiographic findings are reviewed, including skull films and computed tomographic scans. The patient underwent surgical debridement of the lesion, as well as systemic medical therapy with amoxicillin. We review the medical and surgical therapy for such lesions. The differential diagnosis of a posttraumatic scalp swelling is also reviewed.

RESULTS

Good resolution after debridement and antibiotic therapy is reported.

CONCLUSIONS

Surgical intervention is emphasized for the removal of bony sequestrum and nonviable bone while maintaining an intact dura.

Congenital desmoid tumor of the scalp: a histologically benign lesion with aggressive clinical behavior

Desmoid tumors are uncommon benign neoplasms of fibroblastic origin, frequently presenting in the abdomen or abdominal wall of adults. This tumor is well known to general surgeons and pathologists, but it has rarely been reported in the neurosurgical literature. We describe a neonate who presented with a right temporal subscalp tumor at birth. In spite of initial apparent total removal, the tumor recurred twice. We discuss the diagnostic pitfalls encountered in assessing this tumor and the difficulties in distinguishing, in the excised specimens, between desmoid and reactive fibrosis. We suggest that desmoid tumor should be considered in the differential diagnosis of scalp and calvarial masses in children. Complete excision is required to prevent recurrences, and sometimes a multidisciplinary team is needed to secure margin-free resection.

Primary intraosseous meningioma of the temporal bone in an infant. A case report

Primary intraosseous meningioma of the skull bone is a very rare entity. Although it can occur at any age, it is very rare in children. We present a case and review the literature.

Dermoid cyst of the frontal bone away from the anterior fontanel

A case with a midline dermoid cyst of the frontal bone away from the anterior fontanel is reported. Although a few such cases have been reported, detailed descriptions are not given. Possible intracranial extension of these lesions is discussed with review of the pertinent literature.

The frequency and clinical significance of bone involvement in outer canthus dermoid cysts

Periorbital dermoid cysts should be removed because they commonly leak their irritant contents into the surrounding tissues. The underlying bone may, however, be involved in patients with dermoid cysts at the outer canthus. Computed tomography studies of 70 patients (43 men and 27 women, aged 30 months to 63 years, mean 29 years) with proved dermoid cysts of this type were reviewed. The lesion was always unilateral; 34 were on the left. The bone of the lateral wall and superotemporal angle of the orbit showed the following abnormalities, often in combination: pressure erosion in 61 cases and an otherwise abnormal shape, probably developmental, in 55; the dermoid cyst entered a tunnel or canal through the lateral wall in 24; a blind pit or crater in 15; and a cleft in 20; many patients also showed abnormal bone texture. These findings are extremely important for planning adequate surgery, and indicate that bony involvement is much more frequent than previously appreciated.

Scalp cyst with heterotopic brain tissue

A multilocular scalp lesion was noticed at birth in a female infant. There was no underlying skull defect. Histological examination revealed neural tissue staining with S-100 and GFAP, but not with a neurofilament stain, which is in keeping with a glial cell origin. Heterotopic brain tissue is a rare developmental abnormality, which usually has no effect on neurological development. It should be considered in the differential diagnosis of scalp lesions in neonates.

Congenital inclusion dermoid cysts of the scalp

The natural history of congenital inclusion dermoid cysts of the scalp is unknown. We report three cases of this condition, which has been followed from birth for up to ten years. Dermoids are congenital subcutaneous cysts, which gradually flatten and scar over a number of years. The lesions are covered with skin showing focal alopecia but they may be surrounded by a collar of hypertropic hair. Later in life flattened cysts may be mistaken for aplasia cutis, but the history of a cyst at birth allows the clinician to distinguish these two conditions. As these cysts have a potential for intracranial extension, this is an important clinical entity.