Aggressive regrowth and parenchymal invasion following multiple subtotal resection of giant calvarial hemangioma: A rare complication

Background: Skull hemangioma is a rare benign bone tumor, arises from the diploic vessels, and exhibits outward growth pattern, usually sparing the inner table. This is the world’s first report of it’s kind to exhibit aggressive growth pattern of hemangioma following subtotal resection, subsequently invades the brain parenchyma, and leads to catastrophic outcome. Case Description: This 25-year-old gentleman presented with progressive enlargement of a painless scalp swelling within a period of 8 years. Computed tomography scan of brain demonstrated a giant, sclerosed, cauliflower like swelling, having “sunburst pattern” involving fronto-temporo-parietal region. Magnetic resonance imaging showed mixed intensity in both T1- and T2-weighted images with “spoke wheel” appearance. He then underwent subtotal resection for 3 times within a period of 2 years. However, due to rapid aggressive growth involving major part of the calvaria and right orbit, patient party refused to undergo further intervention. He became bed bound and died 6 months after 3 rd resection. Conclusion: This case highlighted the aggressive and invasive clinical course of a benign lesion following subtotal resection. Surgery may play a role in tumor dedifferentiation to more aggressive form; therefore, gross total resection should be attempted in the earlier stage of the disease.