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Cavernous hemangioma of the skull
CAVERNOUS
HEMANGIOMA
OF THE SKULL*
CASE REPORT DEAN H. ECHOLS, M.D. AND AssistantProfessorof Surgery in Charge of Neurosurgery, Tulane University
or
United States Army
SchooI of Medicine NEW
ORLEANS, LOUISIANA
EMANGIOMAS
are tumors composed of newly formed blood vessels. Such growths may be cavernous capillary in type and, when they
H
CAPT. L. R. J. KLEINSASSER,M.C.
sporadic references to the condition have appeared in the literature. In 1930, Bucy and Capp,2 in a review of the Iiterature, found eighteen cases of angioma of the
A
FIG.
I. A
and
B,
B
preoperative
and postoperative
of the patient.
skuI1 in fifty-six cases of hemangioma of bone. Seven years Iater, Anspach3 was able to cohect twenty-one cases of hemangioma involving the skull and reported a case of his own. The most recent review of the Iiterature by Abbott,4 in 1941, reveals only twenty-six reported cases of angioma of the skuI1. He presents an additiona case and since his review, one more case has been recorded.5 These, together with the one we are presenting, bring the tota number of reported cases to twenty-nine. The foIIowing case of cavernous hemangioma of the right fronta bone, including
occur in bone, are more often found in the cranium and spine than in other parts of the skeleton. They are usualIy benign and may or may not cause symptoms. In the case of crania1 hemangiomas their growth is gradua1 and as they increase in size, headaches, vomiting and even conv&ions may be experienced. A definite diagnosis can be made from the characseen in the teristic “ sunray ” appearance roentgen ray films. Operative removal of the tumor, when possibIe, offers the best rest&s. The disease is rare. Since Toynbee’ first described an angioma of the skull in 1845, * From the Tulane University
photographs
School of Medicine and Charity ‘34
Hospital,
New Orleans.
NEW SERIES VOL. LX, No.
the superciliary is reported not of the condition
I
Echols,
KIeinsasser-Hemangioma
arch and orbita plate, only because of the rarity but also because it has
American Journal of Surgery
‘35
areas on its surface. No subjective symptoms were experienced until three years before admission when the patient complained of
FIG. 2. A and a, preoperative roentgenogram showing the “sunray” appearance of the tumor and postoperative roentgenogram showing the defect after remova1.
stated” that operation been groma this size wouId be fatal. CASE
on
heman-
REPORT
E. H., a colored farmer, aged forty-seven, entered Charity HospitaI in New Orleans, March 3, 1941, because of a large tumor of the forehead causing intermittent aching pain. About twelve years before admission he noted
FIG. 3. Bisected specimen. The large white areas are pieces of skull. The intracranial portion of the tumor is much smaller than the extracranial portion.
a smooth, round, hard growth about the size of a pea on the right side of his forehead. For seven years the mass graduaIIy and uniformly increased in size until it became as large as a pecan. For the next four years it grew rapidly. Since then there has been little change. The tumor was not uniformIy hard but had soft
intermittent aching pain in the tumor, particularlv at night. Situated over the right side of the forehead, the mass projected like a horn. (Fig. IA.) It was smooth on its surface, dome-shaped and extended from the eyebrow to a point 6 cm. behind the hair Iine, being entirely to the right of the midline. The skin encasing the mass was freely movable. No pulsation was noted. The mass was 27 cm. in circumference at the base and 21 cm. near the apex. The mass was firm and bony at the base and soft at the apex with areas of firmness interspersed. In the right temporal region were two dilated v-ems, but no bruit was heard over the tumor. Roentgenograms (Fig. 2~) showed a tumor with perpendicular striations arising from the right frontal bone. There was involvement of the superciliary arch and the roof of the orbit. A diagnosis of hemangioma of the skull was made. On March 12, 1941, under a local anesthetic a saggital incision was made over the tumor beginning just above the supra-orbital margin. The two flaps of skin were dissected free from the tumor. The periosteum and temporal muscle were incised around the base of the tumor with the electrosurgical knife. A single trephine was made in the skull. With this as a starting point a groove I cm. in width was made with a rongeur around the base of the tumor. It was necessary to remove parts of the superciliary ridge and roof of the orbit. Bleeding from bone was controIled by application
136
Ame&an
Journal
of Surgery
Echols,
KIeinsasser-Hemangioma
of wax. The tumor (Fig. 3) was separated from the underlying dura with the finger and Iifted off in one piece. The dura was not torn during this procedure. The frontal sinus, which
1943
ConvaIescence was uneventful. (Fig. ZB.) (Fig. IB.) PathoIogic examination of the mass reveaIed a firm, encapsulated tumor measuring 12 cm.
FIG. 4. Microphotograph showing typical cavernous The darker area is a spicule of bone.
had been wideIy opened, was cIosed by suturing the periosteum to the dura. The tumor mass had extended inward as weII as outward and had greatIy depressed the dura and the underlying fronta Iobe. While preparation was being made for closure of the skin, it was noted that the redundant dura had compIetely expanded, indicating an acute subdura1 hematoma. The dura was opened and the Iarge fresh cIot was removed. The surface of the brain appeared normal except that it was flattened and depressed. The bleeding vessel which had produced the subdura1 hematoma was grasped with a forceps and eIectricaIIy coaguIated. The incision in the dura was sutured to the periosteum at various points and the skin cIosed in layers. A drain was left in the wound for twenty-four hours because of the impossibiIity of obtaining compIete hemostasis. The bIood Ioss was considerable but did not f&II expectations and repIacement measures were entirely adequate. There was no shock during or after operation. A postoperative roentgenogram showed the defect in the bone.
APRIL.
hemangioma.
by IO cm. by 8.5 cm. and weighing 360 Gm. It consisted chiefly of hemorrhagic tissue. The microscopic diagnosis was cavernous hemangioma of the skuI1. (Fig. 4.) Fifteen months after operation, on June 19, 1942, the patient was requested to return for There was no evidence of re-examination. recurrence of the tumor at this time. There On cIose questioning, were no compIaints. however, he stated that he no Ionger worked on his farm at noon on hot days because giddiness resuIted. REFERENCES I. TOYNBEE, J. An account of two vascuIar tumors deveIoped in the substance of bone. Lancet, Z: 676, 1845. 2. BUCY, P. C. and CAPP, C. S. Primary hemangioma of bone. Am. J. Roentgenol. CYRad. Tberap., 23: 1, ‘930. 3. ANSPACH, W. E. Sunray hemangioma of bone with speciaI reference to roentgen signs. J. A. M. A., 108: 617, 1937. 4. ABBOTT, W. D. Angioma of the skul1. Ann. Surg., 113: 306, 1941. 5. KAPLAN, A. and KANZAR, M. Sunray hemangioma of the skul1. Report of a case. Arch. Surg., 39: 269, 1939.
HEMANGIOMA
OF THE SKULL*
CASE REPORT DEAN H. ECHOLS, M.D. AND AssistantProfessorof Surgery in Charge of Neurosurgery, Tulane University
or
United States Army
SchooI of Medicine NEW
ORLEANS, LOUISIANA
EMANGIOMAS
are tumors composed of newly formed blood vessels. Such growths may be cavernous capillary in type and, when they
H
CAPT. L. R. J. KLEINSASSER,M.C.
sporadic references to the condition have appeared in the literature. In 1930, Bucy and Capp,2 in a review of the Iiterature, found eighteen cases of angioma of the
A
FIG.
I. A
and
B,
B
preoperative
and postoperative
of the patient.
skuI1 in fifty-six cases of hemangioma of bone. Seven years Iater, Anspach3 was able to cohect twenty-one cases of hemangioma involving the skull and reported a case of his own. The most recent review of the Iiterature by Abbott,4 in 1941, reveals only twenty-six reported cases of angioma of the skuI1. He presents an additiona case and since his review, one more case has been recorded.5 These, together with the one we are presenting, bring the tota number of reported cases to twenty-nine. The foIIowing case of cavernous hemangioma of the right fronta bone, including
occur in bone, are more often found in the cranium and spine than in other parts of the skeleton. They are usualIy benign and may or may not cause symptoms. In the case of crania1 hemangiomas their growth is gradua1 and as they increase in size, headaches, vomiting and even conv&ions may be experienced. A definite diagnosis can be made from the characseen in the teristic “ sunray ” appearance roentgen ray films. Operative removal of the tumor, when possibIe, offers the best rest&s. The disease is rare. Since Toynbee’ first described an angioma of the skull in 1845, * From the Tulane University
photographs
School of Medicine and Charity ‘34
Hospital,
New Orleans.
NEW SERIES VOL. LX, No.
the superciliary is reported not of the condition
I
Echols,
KIeinsasser-Hemangioma
arch and orbita plate, only because of the rarity but also because it has
American Journal of Surgery
‘35
areas on its surface. No subjective symptoms were experienced until three years before admission when the patient complained of
FIG. 2. A and a, preoperative roentgenogram showing the “sunray” appearance of the tumor and postoperative roentgenogram showing the defect after remova1.
stated” that operation been groma this size wouId be fatal. CASE
on
heman-
REPORT
E. H., a colored farmer, aged forty-seven, entered Charity HospitaI in New Orleans, March 3, 1941, because of a large tumor of the forehead causing intermittent aching pain. About twelve years before admission he noted
FIG. 3. Bisected specimen. The large white areas are pieces of skull. The intracranial portion of the tumor is much smaller than the extracranial portion.
a smooth, round, hard growth about the size of a pea on the right side of his forehead. For seven years the mass graduaIIy and uniformly increased in size until it became as large as a pecan. For the next four years it grew rapidly. Since then there has been little change. The tumor was not uniformIy hard but had soft
intermittent aching pain in the tumor, particularlv at night. Situated over the right side of the forehead, the mass projected like a horn. (Fig. IA.) It was smooth on its surface, dome-shaped and extended from the eyebrow to a point 6 cm. behind the hair Iine, being entirely to the right of the midline. The skin encasing the mass was freely movable. No pulsation was noted. The mass was 27 cm. in circumference at the base and 21 cm. near the apex. The mass was firm and bony at the base and soft at the apex with areas of firmness interspersed. In the right temporal region were two dilated v-ems, but no bruit was heard over the tumor. Roentgenograms (Fig. 2~) showed a tumor with perpendicular striations arising from the right frontal bone. There was involvement of the superciliary arch and the roof of the orbit. A diagnosis of hemangioma of the skull was made. On March 12, 1941, under a local anesthetic a saggital incision was made over the tumor beginning just above the supra-orbital margin. The two flaps of skin were dissected free from the tumor. The periosteum and temporal muscle were incised around the base of the tumor with the electrosurgical knife. A single trephine was made in the skull. With this as a starting point a groove I cm. in width was made with a rongeur around the base of the tumor. It was necessary to remove parts of the superciliary ridge and roof of the orbit. Bleeding from bone was controIled by application
136
Ame&an
Journal
of Surgery
Echols,
KIeinsasser-Hemangioma
of wax. The tumor (Fig. 3) was separated from the underlying dura with the finger and Iifted off in one piece. The dura was not torn during this procedure. The frontal sinus, which
1943
ConvaIescence was uneventful. (Fig. ZB.) (Fig. IB.) PathoIogic examination of the mass reveaIed a firm, encapsulated tumor measuring 12 cm.
FIG. 4. Microphotograph showing typical cavernous The darker area is a spicule of bone.
had been wideIy opened, was cIosed by suturing the periosteum to the dura. The tumor mass had extended inward as weII as outward and had greatIy depressed the dura and the underlying fronta Iobe. While preparation was being made for closure of the skin, it was noted that the redundant dura had compIetely expanded, indicating an acute subdura1 hematoma. The dura was opened and the Iarge fresh cIot was removed. The surface of the brain appeared normal except that it was flattened and depressed. The bleeding vessel which had produced the subdura1 hematoma was grasped with a forceps and eIectricaIIy coaguIated. The incision in the dura was sutured to the periosteum at various points and the skin cIosed in layers. A drain was left in the wound for twenty-four hours because of the impossibiIity of obtaining compIete hemostasis. The bIood Ioss was considerable but did not f&II expectations and repIacement measures were entirely adequate. There was no shock during or after operation. A postoperative roentgenogram showed the defect in the bone.
APRIL.
hemangioma.
by IO cm. by 8.5 cm. and weighing 360 Gm. It consisted chiefly of hemorrhagic tissue. The microscopic diagnosis was cavernous hemangioma of the skuI1. (Fig. 4.) Fifteen months after operation, on June 19, 1942, the patient was requested to return for There was no evidence of re-examination. recurrence of the tumor at this time. There On cIose questioning, were no compIaints. however, he stated that he no Ionger worked on his farm at noon on hot days because giddiness resuIted. REFERENCES I. TOYNBEE, J. An account of two vascuIar tumors deveIoped in the substance of bone. Lancet, Z: 676, 1845. 2. BUCY, P. C. and CAPP, C. S. Primary hemangioma of bone. Am. J. Roentgenol. CYRad. Tberap., 23: 1, ‘930. 3. ANSPACH, W. E. Sunray hemangioma of bone with speciaI reference to roentgen signs. J. A. M. A., 108: 617, 1937. 4. ABBOTT, W. D. Angioma of the skul1. Ann. Surg., 113: 306, 1941. 5. KAPLAN, A. and KANZAR, M. Sunray hemangioma of the skul1. Report of a case. Arch. Surg., 39: 269, 1939.