Neuroplastic and reconstructive surgery management of delayed scalp necrosis after multimodal cranial tumor treatment: case report and systematic review

Background Multimodal treatment with preoperative endovascular embolization (PEE) of the external carotid artery (ECA) is employed to reduce intraoperative bleeding and facilitate resection of highly vascular cranial tumors. Ischemic complications have been described, but scalp necrosis remains exceptionally rare. Methods We report a case of delayed scalp necrosis after multimodal treatment of a cranial metastatic follicular thyroid carcinoma and provide a systematic review summarizing its causes and reconstructive management. This study followed the Case Report (CARE) checklist and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results A 51-year-old male developed a 7 × 8 cm occipital scalp necrosis on postoperative day 26 after right ECA embolization, tumor resection, and adjuvant early stereotactic radiosurgery (SR). There was no local infection, and necrosis was attributed to cumulative ischemic injury in a previously embolized vascular bed. Reconstruction was achieved using a large (19 × 12 cm) contralateral rotational flap based on the left superficial temporal (STA) and occipital arteries (OA), supplemented by local advancement of right occipital tissue, resulting in complete healing without complications. Our systematic review identified seven patients across five studies, with scalp necrosis typically occurring within the first postoperative week and managed through debridement, grafts, or flap reconstruction without complications. Conclusion Scalp necrosis following PEE of the ECA for cranial tumor resection is a rare ischemic complication that requires tailored reconstructive management. Anticipatory incision planning at the time of tumor resection enabled preservation of vascularized tissues, including the pericranium, facilitating successful rotational flap reconstruction with implant preservation in this rare complication.