Case Competition 2024 – All submitted cases Case 14 Full-thickness scalp and skull defect with dura mater exposure due to dissociation of pain sensation and anankastic personality disorder
Keywords: Scalp defect, skull defect, chronic automanipulation, anankastic personality disorder
Authors: Martynas Tamulevicius (MD), Peter M. Vogt (MD, Professor) and Vincent Maerz (MD). MH Hannover, Germany
A 66-year-old patient was presented as an emergency case at an external neurological clinic due to noticeable neurological symptoms, including right-sided neglect. The patient had been unconsciously attempting to constantly turn to the right side while in bed for several hours. Additionally, a large oval skull cap defect with dura mater exposure in the occipital region was observed. After ruling out intracranial bleeding, infarction, and cerebrospinal fluid circulation disorders through imaging, the patient was transferred to our clinic for evaluation of possible defect coverage. According to the patient’s medical history, in 2010, he had been treated by otolaryngologists for an extensive nuchal abscess (approximately 10 x 10 cm) with early necrotizing fasciitis and bacteraemia, with positive blood cultures indicating Staphylococcus aureus (penicillin G-sensitive). After multiple debridements and partial wound closure, the clean and gut granulated wound was left to heal by secondary intention. Furthermore, the initial diagnosis of type II diabetes mellitus was made with significant hyperglycaemia (blood glucose level of 30.4 mmol/L, HbA1c of 10.8%). The antidiabetic therapy prescribed at that time was also discontinued by the patient himself 5 years ago, prior to the current presentation. Information obtained from third-party sources (general practitioner, family members, and close friends of the patient) revealed that the patient would frequently scratch his head with his fingers several times a day, often resulting in subungual bloodstains on his fingers. The patient reported experiencing persistent pruritus, especially in the occipital region, since the beginning of the wound healing by secondary intention in the nuchal region.
Before and after
Patient examination
The clinical examination revealed an oval, non-inflammatory scarred area (8.5 x 10 cm) in the high occipital region, painless upon palpation, with beginning scar retractions extending towards the nuchal area and central exposure of the dura mater. There were no wounds observed in the nuchal region. Magnetic resonance imaging (MRI) and computed tomography (CT) scans were performed to rule out intracranial processes. Morphologically, a 5 x 7 cm scalp defect with chronically thickened dura mater was observed.
Pre-Operative Considerations
To exclude the possibility of scar carcinoma, a field biopsy was initially conducted, involving the collection of 12 cutaneous tissue samples from the wound margins. Histopathological examination revealed a chronic inflammatory reaction of the dermis with acanthosis and hyperkeratosis, without evidence of malignancy. Additionally, an interdisciplinary assessment of the poorly managed type II diabetes mellitus and psychiatric evaluation was conducted. With an HbA1c level of 7.2%, fasting glucose level of 6.8 mmol/L, and a long-standing diagnosis of diabetic polyneuropathy, metformin therapy was initiated. The psychiatric consultation confirmed APD. Furthermore, indications of the patient’s reduced health awareness and limited social engagement were observed.
Step 1: Computed tomographic (A and B) and magnetic resonance imaging (C and D) visualization of the skull defect.
A 5 x 7 cm scalp defect with chronically thickened dura mater was observed.
Step 2: Field biopsy with the extraction of 12 cutaneous tissue samples from the wound margin.
To exclude the possibility of scar carcinoma, a field biopsy was initially conducted.
Step 3: Intraoperative view for anastomosis planning
Defect coverage using a free myocutaneous latissimus dorsi flap with anastomosis to the right facial artery (intraoperatively). Marked with arrows: facial artery and vein (red and blue rubber loops) and marginal mandibular branch of the facial nerve (white rubber loop).
Post-Operative Plan
– follow-up appointments at 3, 6 months, and 1 year; – ambulant psychiatric support to prevent self-harm behavior; – ambulant diabetic care for regular therapy monitoring; – scar massage for optimal scar healing.
- A cranial defect with exposed dura mater caused by psychiatric-induced self-mutilation over a period of 12 years represents an extremely rare aetiology
- In cases of chronic wound defects, it is crucial to exclude the possibility of a tumour entity. Malignant processes, such as basal cell carcinoma, squamous cell carcinoma (including scar carcinoma), or possible tumour metastasis.
- In psychiatric patients with chronic wounds, self-harm behavior should always be considered.
- The patient’s untreated type II diabetes mellitus and pre-existing diabetic polyneuropathy may contribute to altered sensitivity.
- Chronic pruritus in the occipital region could stem from surgical treatment of infection and subsequent healing phases.
References
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