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: February 18, 2015

CHIEF COMPLAINT: 1-year history of a nodule on the vertex of the scalp

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

LABORATORY TESTS:

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.