PMC8769418_01
Pre-therapeutic images. (A) The mass was soft with mild tenderness in the midline occipital region of the scalp (80 x 80 mm). (B, C) The tumor showed no calcification; bone destruction was observed subcutaneously in the occipital cranial bone corresponding to the tumor. (D) On iopamidol-enhanced CT of the tumor showed heterogeneous enhancement. (E) In three-dimensional CT imaging, the skull defect presented above SSS. (F) Selective occipital artery angiography showed multiple feeding arteries for the tumor (arrowhead). (G) There was no connection between superior sigmoid sinus and tumor. CT: computed tomography, SSS: superior sagittal sinus.
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F1
Upon physical examination, an oval elastic soft mass was observed in the subcutaneous layer of the occipital region (Fig. 1A). Computed tomography (CT) of the head revealed that a 15-mm diameter round skull defect was located just beneath the mass (Figs. 1B and 1C) and demonstrated heterogeneous enhancement of the subcutaneous mass (Fig. 1D). In three-dimensional CT imaging, the superior sagittal sinus (SSS) ran underneath the skull defect (Fig. 1E). The selective occipital artery angiogram revealed the development of feeding arteries around the mass (Fig. 1F). And there was no connection between superior sigmoid sinus and tumor (Fig. 1G). Though dura matter beneath the skull defect was slightly discolored (Fig. 1B), normal color dura tissue was identified with scraping off the thickened surface.
Preoperative preparation and operative findings. (A) Sigmoid-shaped skin incision was designed and the stream of bilateral occipital arteries (arrowheads) were identified preparing for ligation. (B) Tumor is of an intradermal origin showing a heterogeneously red color, easily hemorrhagic. Bilateral occipital arteries (arrowheads) were ligated in order to control bleeding. (C) A surgical view after the mass debulking. (D) The surgical view of marginal resection of the skin and the cranial bone in the 2nd operation.
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F2
First, an atypical growing hematoma was suspected, and the mass was surgically removed (Fig. 2A). Before the removal procedure, bilateral occipital arteries were ligated to control bleeding (Fig. 2B) and the mass was mostly resected (Fig. 2C). A month later with pathological diagnosis of DFSP, in the second operation, the tumor was resected by wide excision with 30 mm margins with the local skin, subcutaneous tissue, and periosteum removed together (Fig. 2D).