Cranial Venous Anomaly in Frontal Lobe Treated by Embolization and Scalp Reconstruction

Introduction Venous anomalies are vascular malformations often characterized by a starburst pattern of smaller veins converging into larger veins. They are typically benign and discovered incidentally. Here, we describe a unique case of a venous anomaly arising in the frontal lobe with trans‐osseous egress into the forehead scalp. Methods We performed a thorough clinical evaluation and work‐up in preparation for a case report. Medical history, clinical presentation, and advanced imaging studies were reviewed. Results A 60‐year‐old male with a history of hypertension, hyperlipidemia, and Hepatitis C presented to the neuroendovascular clinic for a longstanding vascular malformation of the forehead. The lesion was first identified at the age of 12 in Mexico, where he underwent two forehead surgeries in the 1970s. He was informed that a residual remained, but did not undergo any further procedures. The lesion remained relatively stable; however, he noted progressive enlargement over several months before presentation. The patient reported that the lesion expands when leaning forward and during sleep, suggestive of gravity dependence. He also reported a sense of increased pressure when bending forward and expressed anxiety about potential bleeding, though he denied prior hemorrhage. The lesion was non‐tender at rest but became tender with flexion and palpation. Physical examination revealed an irregular, asymmetric, hyperpigmented plaque over the forehead adjacent to the midline measuring 8.1×1.2×4.8 cm, with a verrucous surface and hyperkeratosis (Figure 1A). With the patient leaning forward (1B), there was expansion of the lesion with non‐pulsatile fluid. The patient's neurological examination was intact. Non‐contrast CT head demonstrated thinning of the underlying frontal bone without signs of prior craniotomy, infarct, or hemorrhage (1C). CTA head showed the lesion to enhance, though hypodense relative to intracranial arteries, suggestive of underlying venous involvement (1D). T1 MRI pre‐ and post‐contrast showed enhancement of the lesion (1E‐F). T2 demonstrated flow voids in the region (1G), with MRA suggesting a predominantly venous pathology (1H). Digital subtraction angiography confirmed a venous anomaly in the frontal lobe without early arteriovenous shunting. The study (right internal carotid injection, lateral projection) revealed delayed trans osseous venous egress into the forehead scalp (1I arterial, 1J capillary, 1K early venous, 1L late venous phases). Conclusion After a multidisciplinary discussion including the neuroendovascular, neurosurgery, and plastic surgery teams, a decision was made to treat the lesion with a staged approach. After placement of tissue expanders, combined embolization and resection of the lesion, followed by scalp reconstruction, was performed.