Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 181-184

Intramuscular scalp hemangioma in an adult female: A rare case report


1 Department of Cardiothoracic and Vascular Surgery, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
2 Department of General Surgery, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India

Date of Submission27-Feb-2021
Date of Acceptance25-Jun-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Deep Nareshkumar Patel
Department of General Surgery, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_23_21

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  Abstract 


Hemangiomas are the benign tumors of vascular origin. They are the most common tumor in infants and children (10% incidence) but rare in adults. They are more common in girls. They are more commonly found in head and neck region and most commonly located in skin and subcutaneous tissue. They are rarely found in the intramuscular location (0.8% incidence). This article represents a rare case report of intramuscular scalp hemangioma located in the right temporalis muscle in a 26-year-old female presented with chief complaint of headache, which was confirmed by radiological investigations. Surgical excision was done, and approximately 2 cm × 2 cm-sized lesion was excised.

Keywords: Hemangioma, intramuscular, scalp, temporalis, vascular


How to cite this article:
Sharma TR, Patel DN, Shah AJ. Intramuscular scalp hemangioma in an adult female: A rare case report. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:181-4

How to cite this URL:
Sharma TR, Patel DN, Shah AJ. Intramuscular scalp hemangioma in an adult female: A rare case report. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:181-4. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/181/336017




  Introduction Top


Hemangiomas are benign (noncancerous) tumor made up of blood vessels. They are more common in females.[1] There are many types of hemangiomas, and they can occur throughout the body, including in skin, muscle, bone, and internal organs. Most hemangiomas occur on the surface of the skin or just beneath it. They often develop on the face and neck and can vary greatly in color, shape, and size. Hemangiomas most commonly develop in the upper and lower extremities, but rarely, it can also develop in the scalp. Because hemangiomas very rarely become cancerous,[2] most do not require any medical treatment. Intramuscular hemangiomas are rare in occurrence (0.8% incidence). In most cases of hemangioma, treatment does not involve surgery. Indications of surgical excision of hemangioma are:- Hemangiomas that are deep in the muscles or bone, noninvoluted hemangiomas[3] and hemangiomas that are causing problems with vision(intraocular hemangiomas), breathing(intranasal hemangiomas) or eating(intraoral hemangiomas). Hemangiomas of the infantile age have been reported in the literature, but hemangiomas of the adult age and located in the scalp in the intramuscular location are very rare in occurrence and not reported in any literature. Here, we report a case of intramuscular hemangioma of the scalp located deep in the right temporalis muscle in a 26-year-old adult female presented with headache and without evident swelling and skin color changes surgically excised without any complications. Most hemangiomas are usually painless,[4] but hemangiomas located deep in the muscles and bones may cause pain.[2] For the rarity of occurrence of this vascular tumor in intramuscular location, it compelled us to report our case in this prestigious journal.


  Case Report Top


A 26-year-old female patient, homemaker, resident of Sanchore, Rajasthan, came to our cardiothoracic and vascular surgery outpatient department with chief complaints of dull-aching headache of the right temporal region for the last 10 years, which was aggravated by strenuous work. It had increased in severity for the last 7 months. There were no associated complaints of fever, visual disturbance, seizures, pressure symptoms, vomiting, discoloration of scalp skin, and swelling over the scalp region and/or any other part of the body. She had no comorbidities and no history of any previous operative interventions. She was taking tablet paracetamol for headache and had consulted many physicians for the same complaint. However, there was no relief.

On examination, there was no evident swelling or skin color changes over the right scalp region. The patient had no focal neurological deficit.

On ruling out other causes of headache and radiological investigations, the patient was diagnosed with intramuscular scalp hemangioma located in the right temporalis muscle.

Investigations

NCCT BRAIN(NONCONTRAST CT SCAN OF BRAIN) WITH CT ANGIOGRAPHY OF HEAD AND NECK VESSELS (BOTH INTRACRANIAL AND EXTRACRANIAL VESSELS) report was suggestive of approximately 3cm * 1cm * 3cm sized capillary hemangioma of the right scalp region located intramuscularly within right temporalis muscle without any evident feeder vessels. The plates of NCCT BRAIN & CT ANGIOGRAPHY OF HEAD & NECK VESSELS are shown in [Figure 1]. Report was suggestive of approximately 3.4 cm × 1 cm × 3 cm-sized capillary hemangioma of the right scalp region located intramuscularly within right temporalis muscle without any evident feeder vessels.
Figure 1: NCCT brain with computed tomography angiography of head and neck region (both intracranial and extracranial)

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Preoperative evaluation

  • All routine blood investigations (complete blood count, renal function test, prothrombin time, international normalized ratio, and liver function tests) were within normal limit
  • Human immunodeficiency virus assay and hepatitis B surface antigen test were negative
  • Chest X-ray was normal
  • Electrocardiogram was normal
  • Pulmonary function test was normal
  • Two-dimensional echo was normal.


After all preoperative routine investigations and workup, the patient was planned for elective surgery for excision.

Preoperative surface marking of the lesion was done under ultrasound guidance, and site of the incision was marked after proper planning, evaluation, and discussion [Figure 2].
Figure 2: Preoperative surface marking of lesion and incision

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Intraoperative findings

  • Approximately 2 cm × 2 cm-sized well-defined, well-circumscribed lesion located in the intramuscular location within right temporalis muscle [Figure 3] and [Figure 4] was excised with adequate margins and specimen was sent for histopathological examination [Figure 5].
Figure 3: Intraoperative picture of scalp hemangioma (held with forceps)

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Figure 4: Image of right temporal region after excision

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Figure 5: Excised histopathological specimen of hemangioma

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Histopathological examination (biopsy) report was suggestive of:

  • Normal skeletal muscle and mature adipose tissue with few dilated blood vessels
  • Diagnosis - “capillary hemangioma.”


Postoperative course

  • The patient was discharged on the postoperative day 10 with complete suture removal and without any complaints and complications.



  Discussion Top


Hemangioma is the most common tumor in children (10% of term deliveries). It is benign vascular endothelial tumor. It is more common in females than males (3:1). It shows cellular endothelial hyperplasia with increased mast cells. Onset is few weeks after birth with triphasic growth,[5] showing proliferation, plateau, and gradual involution over 5–7 years.[5] Due to uninhibitory growth signals, it grows also in adult age and does not involute.[6] Hence, it can also manifest in adult age. It is commonly seen in skin and subcutaneous tissue but can occur everywhere in the body such as in liver, brain, and lungs. It can also rarely occur in the intramuscular location (0.8% incidence). It grows rapidly in 1 year and gradually disappears in 7 years. Early proliferative lesion is bright red[7] and irregular; deep lesion is bluish colored. Involution causes color fading, softness, shrinkage leaving crepe paper-like area. Superficial hemangiomas of the skin and subcutaneous region are mostly centrally located in head and neck region (60%). Deep hemangiomas of the intramuscular or bony origin are located most commonly in the upper and lower extremities but rarely can also be found in the scalp region.

Types of hemangiomas

  1. Capillary hemangiomas
  2. Cavernous hemangiomas.


Capillary hemangiomas

It is most common type of hemangioma. It is also called as “strawberry hemangioma.” It is more common in White girls. Male: female ratio is 3:1. It is common in head and neck region. It is clinically compressible, warm with bluish surface.[4] Bleeding can occur after minor trauma and also ulceration. It involves mostly skin and subcutaneous tissue and muscles also as in our case. After 1 year of age, it slowly begins to disappear and completely regresses in 7–8 years (70%). Due to uninhibited genetic growth signals, it does not completely involute and can manifest in adult life as manifested in our patient.

Cavernous hemangiomas

It is present at birth and consists of a multiple venous channels. Its size increases gradually and may cause problems. It often contains feeding vessels which is of surgical importance. It can occur at following sites: Head, neck, face, limbs, tongue, liver, and other internal organs.

Features

It is smooth, soft, well-localized, warm, fluctuant, compressible, nonpulsatile swelling with bluish surface occurring in the skin and subcutaneous tissue (often in mucosa-like oral cavity) without transillumination. Compressibility and bluish surface are diagnostic. It is usually nontender unless it gets infected or undergoes thrombosis or causes hemorrhage.

Hemangiomas are usually associated with genetic syndromes such as Klippel-Trenaunay-Weber syndrome,[5] Kasabach Merritt syndrome, Sturge-Weber syndrome, Maffucci syndrome, Proteus syndrome, and Osler-Weber-Rendu syndrome.[3]

Clinical features

Hemangiomas most commonly manifest as a swelling or skin color changes. They can rarely manifest without swelling as in our patient. Pain is an uncommon symptom of hemangioma as manifested in our patient. Pain is a symptom of deeply located hemangiomas of the muscle and bony origin.

Diagnosis

Hemangiomas are usually diagnosed by radiological investigations. It can be diagnosed clinically if there is evident skin color changes or palpable swelling. The diagnostic investigation of choice for hemangiomas are magnetic resonance (MR) imaging (soft-tissue local part)[8] - it helps identify the site of lesion and size of the lesion. MR or computed tomography (CT) angiography is done to find out the feeder vessel and abnormal communication with vessels and rule out other vascular malformations. In our case, ncct brain and ct angiography of head and neck vessels was showing intramuscular scalp hemangioma in right temporalis muscle without feeder vessels.

Ultrasound of the local part and Doppler help for preoperative surface marking of lesion and for locating the feeder vessels.

Histopathological examination (biopsy) of the excised specimen helps confirm the diagnosis.

Fine needle aspiration cytology and true-cut biopsy of the hemangiomas are contraindicated because it is highly vascular tumor.

Treatment

Various treatment options are there for treatment of hemangioma in this modern era.

  1. Wait-and-watch policy – Most hemangiomas of children and infants are treated by wait and careful watching as they usually regress at 7 years of age
  2. Systemic/oral and intralesional steroid therapy for rapidly growing hemangiomas
  3. Antiangiogenic interferon 2a is the modern treatment option
  4. Laser ablation-diode pulsed laser is becoming popular because of good control of bleeding. Neodymium: yttrium-aluminum-garnet CO2 laser is equally effective for skin hemangiomas
  5. Ligation of feeding artery and later stage excision for the large hemangiomas with evident feeder vessels
  6. Embolization - Preoperative therapeutic embolization facilitates surgical excision by reducing the intraoperative blood loss. Materials used are foam, plastic spheres, stainless/platinum steel coils, ethanol and polyvinyl alcohol. Procedure is done by interventional radiologist under image intensifier
  7. Sclerosant therapy – It is the initial first line of therapy. It causes aseptic thrombosis and fibrosis of cavernous hemangioma with less vascularity and smaller size. It is directly injected into the lesion. Sodium tetradecyl sulfate[9]/hypertonic saline are used. Often multiple injections are needed to achieve complete required effect
  8. Excision – Surgical excision is the gold standard treatment for hemangioma. Surgical excision with adequate margins is required to prevent recurrence. For nonpalpable intramuscular hemangioma, recurrence can be prevented by using preoperative ultrasound-guided hookwire localization.[10]


Indications for surgical excision-retained tissue after involution, deeply located hemangiomas as in intramuscular or bony location, uncontrolled growth, accidental hemorrhage, functional impairment such as vision or hearing, and debilitating symptoms such as pain and/or pressure symptoms.

In our case, hemangioma was located in intramuscular location and the patient was of an adult age and having chronic dull-aching headache; hence, we planned for surgical excision.

Complications

Hemorrhage, disseminated intravascular complications, thrombosis, infection, ulceration and septicemia, erosion into adjacent bone, high-output cardiac failure.

Differential diagnosis

  • Lymphangioma is brilliantly transilluminant unless it is infected or fibrosed.
  • Lipoma, cold abscess, and lymph cyst – clinically, it is easy to differentiate.



  Conclusion Top


Intramuscular hemangiomas in the scalp region are rare in occurrence and should always be considered in differential diagnosis of chronic dull-aching headache.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rastogi A, Srivastava N, Vijay V, Agarwal S. Intramuscular cavernous hemangioma of the triceps muscle. Indian J Vasc Endovasc Surg 2015;2:122-4.  Back to cited text no. 1
  [Full text]  
2.
Patten DK, Wani Z, Kamineni S. Intramuscular cavernous haemangioma of the triceps. Int J Surg Case Rep 2011;2:86-9.  Back to cited text no. 2
    
3.
Mulligan PR, Prajapati HJ, Martin LG, Patel TH. Vascular anomalies: Classification, imaging characteristics and implications for interventional radiology treatment approaches. Br J Radiol 2014;87:20130392.  Back to cited text no. 3
    
4.
Melman L, Johnson FE. Intramuscular cavernous hemangioma. Am J Surg 2008;195:816-7.  Back to cited text no. 4
    
5.
Servelle M. Klippel and Trénaunay's syndrome. 768 operated cases. Ann Surg 1985;201:365-73.  Back to cited text no. 5
    
6.
Cohen MM Jr. Vascular update: Morphogenesis, tumors, malformations, and molecular dimensions. Am J Med Genet A 2006;140:2013-38.  Back to cited text no. 6
    
7.
Enjolras O. Classification and management of the various superficial vascular anomalies: Hemangiomas and vascular malformations. J Dermatol 1997;24:701-10.  Back to cited text no. 7
    
8.
Wierzbicki JM, Henderson JH, Scarborough MT, Bush CH, Reith JD, Clugston JR. Intramuscular hemangiomas. Sports Health 2013;5:448-54.  Back to cited text no. 8
    
9.
Berenguer B, Burrows PE, Zurakowski D, Mulliken JB. Sclerotherapy of craniofacial venous malformations: Complications and results. Plast Reconstr Surg 1999;104:1-11.  Back to cited text no. 9
    
10.
Wang CS, Wu PK, Chiou HJ, Chen CF, Chen WM, Liu CL, et al. Nonpalpable intramuscular hemangioma treated with hookwire localization and excision. J Chin Med Assoc 2014;77:426-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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