Thursday, March 15, 2007

Infant with Scalp Mass

The patient is a twenty-week-old infant with a scalp mass present for 2-3 months. It appears to be growing slowly. He was seven weeks premature; but otherwise all milestones have been normal. He had a type one intracranial bleed post partum but it was not complicated. He did have scalp vein IVs whilst in hospital, but it's unclear where they were.

The examination shows a 4x2.5 cm in diameter freely movable mass on the left parietal area. It feels firm. Skin and hair normal over it (in the photo it the hair looks a bit sparser over the lesion). Ultrasound was done and was interpreted as normal.

The mass looks benign. Do you have any suggestions about what this might represent and what to do at this point? Skull x-ray and CT may be indicated, however, I thought I'd get some opinions first.


  1. Hi David,
    One thing is that this is a nevoid condition.
    I feel that the question is whether it is of vascular or melanocytic origin. I get to see, infrequently though, that these surface into a vascular nevus or melanocytic nevus.
    A regular follow-up with serial photographs will reveal the occultness in these cases.
    Some suggestions from others?

  2. Melanie AustinMarch 16, 2007

    From Melanie Austin

    Interesting case....I have a number of questions.
    1.Mode of delivery - vacuum delivery??
    2. Well demarcated?
    3. What exactly did the U/S show ??no evidence for
    cavernous hemangioma. not cystic??
    4. Is it hard ?? calcification secondary to traumatic
    delivery or scalp IV infiltration
    5. Are the sagital sutures normal
    6. Not knowing the answer to any of 2 cents
    would be to have a very low threshold for CT to
    further delineate mass.
    7.Is growth and development normal for adjusted age?
    Looking forward to hearing the outcome

  3. Erica KatesMarch 16, 2007

    Was there any calcification visible on the ultrasound? My guess would be some sort of complication following a scalp IV, such as a calcified hematoma or fat necrosis, although the fact that it seems to be growing would contradict those diagnoses. A lipoma, perhaps? That would show up as normal on an ultrasound. I have seen a few scalp lipomas although most were smaller and in the occipital region.

    Erica Kates, M.D.
    Northamptin, MA

  4. Erica KatesMarch 16, 2007

    This comment has been removed by a blog administrator.

  5. Brian MaurerMarch 16, 2007

    From Brian Maurer, PA-C
    Enfield, CT

    There are a number of risk factors in this infant’s history: (1) prematurity of 33 weeks, (2) an intracranial bleed post-partum, and (3) insertion(s) of scalp vein needles.

    The mass is firm, freely moveable, and growing.

    The ultrasound is reported as “normal.” I don’t know what that means. Is this a cystic or solid mass? Is it solely extracranial, or does it communicate with intracranial structures?

    To my way of thinking, it is imperative to ascertain whether this is a communicating lesion with the brain. An MRI would be the imaging study of choice. Sedation would be required, so the test should be done at a center where folks skilled in administering sedatives to infants will be able to monitor the child closely.

    Extracranial brain tissue without a direct connection to the brain itself may be an isolated cutaneous embryonic defect, usually on occipital or parietal areas of the scalp. It is also known as heterotopic brain tissue or cutaneous ectopic brain (CEB). CEB may be an isolated embryonic rest or a congenital herniation through the skull with an eventual loss of connection.>

    Depending on the outcome of the study, you might need to involve a pediatric neurosurgeon.


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