Case and Research Letter
Tuberous Parietal Lesion Secondary to Sirsasana, the Yoga Headstand Posture
Lesión tuberosa parietal secundaria a Sirsasana, una postura de yoga invertida
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Lesión tuberosa en la región interparietal. B. Lesión tuberosa de morfología ovalada, de 10<span class="elsevierStyleHsp" style=""></span>cm de longitud anteroposterior por 6<span class="elsevierStyleHsp" style=""></span>cm de ancho y superficie erosivo-costrosa en la región central.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. García-Martín, M. Llamas-Velasco, J. Fraga, A. García-Diez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "García-Martín" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Llamas-Velasco" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Fraga" ] 3 => array:2 [ "nombre" => "A." 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García-Martín, M. Llamas-Velasco, J. Fraga, A. García-Diez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "García-Martín" "email" => array:1 [ 0 => "pgarciamartin@aedv.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Llamas-Velasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Fraga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "García-Diez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesión tuberosa parietal secundaria a <span class="elsevierStyleItalic">Sirsasana</span>, una postura de yoga invertida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 589 "Ancho" => 1301 "Tamanyo" => 191351 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Biopsy of the parietal region of the scalp (hematoxylin-eosin, original magnification ×2; panoramic image) B, Hematoxylin-eosin, original magnification ×4. Histopathological findings: marked orthokeratotic hyperkeratosis and mild acanthosis; focal dermal fibrosis with proliferation of small vessels and perivascular lymphocytic infiltrates.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sirsasana is one of the most common inversion postures in yoga and is proposed to increase blood flow to the brain, improving memory and other intellectual functions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> When practicing this posture the body weight rests on the central-parietal region of the cranium. Beginners should maintain this posture for 1<span class="elsevierStyleHsp" style=""></span>min, subsequently increasing to 5<span class="elsevierStyleHsp" style=""></span>min. The posture should be performed under the supervision of an instructor to avoid injury.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe a reactive skin injury caused by long-term practice of Sirsasana.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 62 year-old man with no relevant past medical history other than the practice of an inverted yoga posture for 30<span class="elsevierStyleHsp" style=""></span>minutes several times a day since the age of 15. He presented with a persistent, asymptomatic, raised lesion in the interparietal region that had appeared more than 20 years previously. The size of the lesion had increased during the first few years and then subsequently stabilized. Occasional ulceration and infection of the lesion resolved spontaneously or after antibiotic treatment for approximately 10 days. Physical examination revealed a hard, oval-shaped, tuberous lesion in the interparietal region of about 10<span class="elsevierStyleHsp" style=""></span>cm in anteroposterior length and 6<span class="elsevierStyleHsp" style=""></span>cm in width with a centrally eroded surface (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>,<span class="elsevierStyleHsp" style=""></span>A and B). Blood tests revealed no significant abnormalities. Radiograph of the skull showed an increase in soft tissue in the parietal region and associated periosteal reaction. Based on these findings, a contrast-enhanced computed tomography scan of the brain was performed, revealing an extracranial soft-tissue mass in the upper frontal convexity along the midline, with discrete underlying periosteal reaction and no clear involvement of the outer table of the diploe, consistent with a reactive process. Skin biopsy showed marked orthokeratotic hyperkeratosis and mild epidermal acanthosis. The dermis showed focal fibrosis with proliferation of small vessels, dense perivascular lymphocytic infiltrates, and isolated siderophages (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>,<span class="elsevierStyleHsp" style=""></span>A and B). Magnetic resonance imaging of the brain revealed thickening of extracranial soft tissue at the level of the coronal and sagittal sutures and the external table. The latter showed hypointensity in all sequences indicating sclerotic bone reaction. These findings were consistent with fibrotic changes affecting the extracranial soft tissues and sclerotic bone reaction in the underlying cortical bone (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient continues to practice yoga at the same frequency and intensity, despite being warned of the probable link between that activity and the lesion.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lesion remains stationary after 24 months of follow-up.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the diagnosis of frequently ulcerous, tuberous lesions of the cranium, the first step is to rule out soft-tissue tumor. The majority of soft-tissue tumors present clinically as deep, slow growing masses, and the differential diagnosis is established based on histopathology.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Imaging tests allow for better delineation of the lesion and help to determine its relationship with adjacent structures, and thus should be performed before conducting histological studies.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Once a tumoral origin is ruled out, various reactive lesions should be considered, particularly nodular fasciitis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and cranial fascitis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Both are benign fibroblastic proliferations of unknown etiology, sometimes associated with previous trauma.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These lesions present clinically as firm, well-defined masses that initially grow rapidly and then stabilize,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> as seen in our patient. Both forms of fasciitis share similar histological features, with loose, disorganized bundles formed by the proliferation of large spindle cells, myofibroblastic differentiation, no pleomorphism, and abundant non-atypical mitoses.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> In our case the biopsy ruled out fasciitis, leading to a diagnosis of reactive lesion secondary to long-term practice of Sirsasana. We believe that the development of this lesion was mainly due to the dedication of our patient to his exercises, which considerably exceeded the recommended daily duration.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although yoga exercises are usually safe and promote health, some risks are associated with certain poses, such as inverted postures.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> From the dermatological point of view we have not found an association between skin lesions and the practice of yoga. However, some problems have been described in connection with the practice of Sirsasana. For example, intraocular pressure can be increased in healthy individuals, an effect that is reversed after cessation of the inverted posture (this increase may be more pronounced in people with glaucoma or optic neuropathy secondary to glaucoma,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and may be associated with the progression of glaucoma<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>). Moreover, the central retinal vein can become occluded due to vascular thrombosis caused by an intermittent increase in conjunctival venous pressure and a decrease in venous drainage.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Finally, cervical compressive myelopathy and cervical listhesis can be caused by the biomechanical alterations induced by the inverted posture.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Given the steady increase in the number of people practicing yoga daily, we believe that the dermatologist should be aware of the possible complications associated with this practice and should be alert to associated skin problems that may occur.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Martín P, Llamas-Velasco M, Fraga J, García-Diez A. Lesión tuberosa parietal secundaria a <span class="elsevierStyleItalic">Sirsasana</span>, una postura de yoga invertida. Actas Dermosifiliogr. 2014;105:724–726.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 860 "Ancho" => 1300 "Tamanyo" => 156654 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Tuberous lesion in the interparietal region. B, Oval-shaped tuberous lesion 10<span class="elsevierStyleHsp" style=""></span>cm in anteroposterior length and 6<span class="elsevierStyleHsp" style=""></span>cm wide with central surface erosion and crusting.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 589 "Ancho" => 1301 "Tamanyo" => 191351 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Biopsy of the parietal region of the scalp (hematoxylin-eosin, original magnification ×2; panoramic image) B, Hematoxylin-eosin, original magnification ×4. Histopathological findings: marked orthokeratotic hyperkeratosis and mild acanthosis; focal dermal fibrosis with proliferation of small vessels and perivascular lymphocytic infiltrates.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 828 "Ancho" => 950 "Tamanyo" => 100548 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging scan. Note the thickening of extracranial soft tissues (skin, subcutaneous tissue, and galea) and the external table, which shows hypointensity.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliografía" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Progressive optic neuropathy in congenital glaucoma associated with the Sirsasana yoga posture" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.S. De Barros" 1 => "S. Bazzaz" 2 => "M.E. Gheith" 3 => "G.A. Siam" 4 => "M.R. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 10 | 15 |
| 2024 Octubre | 86 | 38 | 124 |
| 2024 Septiembre | 93 | 33 | 126 |
| 2024 Agosto | 126 | 60 | 186 |
| 2024 Julio | 80 | 31 | 111 |
| 2024 Junio | 80 | 58 | 138 |
| 2024 Mayo | 70 | 31 | 101 |
| 2024 Abril | 64 | 24 | 88 |
| 2024 Marzo | 73 | 34 | 107 |
| 2024 Febrero | 68 | 33 | 101 |
| 2024 Enero | 68 | 37 | 105 |
| 2023 Diciembre | 77 | 25 | 102 |
| 2023 Noviembre | 67 | 34 | 101 |
| 2023 Octubre | 55 | 11 | 66 |
| 2023 Septiembre | 84 | 25 | 109 |
| 2023 Agosto | 40 | 20 | 60 |
| 2023 Julio | 65 | 30 | 95 |
| 2023 Junio | 60 | 21 | 81 |
| 2023 Mayo | 66 | 25 | 91 |
| 2023 Abril | 67 | 18 | 85 |
| 2023 Marzo | 76 | 34 | 110 |
| 2023 Febrero | 58 | 20 | 78 |
| 2023 Enero | 69 | 21 | 90 |
| 2022 Diciembre | 65 | 37 | 102 |
| 2022 Noviembre | 42 | 26 | 68 |
| 2022 Octubre | 41 | 16 | 57 |
| 2022 Septiembre | 24 | 39 | 63 |
| 2022 Agosto | 41 | 27 | 68 |
| 2022 Julio | 34 | 34 | 68 |
| 2022 Junio | 164 | 31 | 195 |
| 2022 Mayo | 35 | 36 | 71 |
| 2022 Abril | 50 | 55 | 105 |
| 2022 Marzo | 44 | 40 | 84 |
| 2022 Febrero | 38 | 33 | 71 |
| 2022 Enero | 63 | 33 | 96 |
| 2021 Diciembre | 44 | 35 | 79 |
| 2021 Noviembre | 36 | 42 | 78 |
| 2021 Octubre | 43 | 45 | 88 |
| 2021 Septiembre | 35 | 44 | 79 |
| 2021 Agosto | 40 | 34 | 74 |
| 2021 Julio | 43 | 43 | 86 |
| 2021 Junio | 19 | 45 | 64 |
| 2021 Mayo | 34 | 27 | 61 |
| 2021 Abril | 73 | 83 | 156 |
| 2021 Marzo | 57 | 28 | 85 |
| 2021 Febrero | 58 | 39 | 97 |
| 2021 Enero | 34 | 22 | 56 |
| 2020 Diciembre | 35 | 19 | 54 |
| 2020 Noviembre | 17 | 12 | 29 |
| 2020 Octubre | 17 | 12 | 29 |
| 2020 Septiembre | 30 | 13 | 43 |
| 2020 Agosto | 27 | 17 | 44 |
| 2020 Julio | 25 | 19 | 44 |
| 2020 Junio | 43 | 32 | 75 |
| 2020 Mayo | 24 | 15 | 39 |
| 2020 Abril | 33 | 15 | 48 |
| 2020 Marzo | 33 | 13 | 46 |
| 2020 Febrero | 2 | 0 | 2 |
| 2020 Enero | 4 | 1 | 5 |
| 2019 Diciembre | 8 | 9 | 17 |
| 2019 Noviembre | 4 | 4 | 8 |
| 2019 Octubre | 0 | 7 | 7 |
| 2019 Septiembre | 12 | 5 | 17 |
| 2019 Agosto | 4 | 2 | 6 |
| 2019 Julio | 2 | 5 | 7 |
| 2019 Junio | 5 | 6 | 11 |
| 2019 Mayo | 2 | 11 | 13 |
| 2019 Marzo | 2 | 6 | 8 |
| 2019 Febrero | 0 | 1 | 1 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Mayo | 0 | 1 | 1 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Marzo | 1 | 2 | 3 |
| 2018 Febrero | 37 | 9 | 46 |
| 2018 Enero | 47 | 12 | 59 |
| 2017 Diciembre | 39 | 5 | 44 |
| 2017 Noviembre | 47 | 8 | 55 |
| 2017 Octubre | 28 | 3 | 31 |
| 2017 Septiembre | 37 | 12 | 49 |
| 2017 Agosto | 36 | 23 | 59 |
| 2017 Julio | 28 | 8 | 36 |
| 2017 Junio | 40 | 21 | 61 |
| 2017 Mayo | 34 | 15 | 49 |
| 2017 Abril | 33 | 29 | 62 |
| 2017 Marzo | 27 | 12 | 39 |
| 2017 Febrero | 32 | 11 | 43 |
| 2017 Enero | 18 | 8 | 26 |
| 2016 Diciembre | 33 | 11 | 44 |
| 2016 Noviembre | 39 | 10 | 49 |
| 2016 Octubre | 49 | 8 | 57 |
| 2016 Septiembre | 55 | 4 | 59 |
| 2016 Agosto | 2 | 1 | 3 |
| 2016 Julio | 11 | 1 | 12 |
| 2016 Junio | 17 | 10 | 27 |
| 2016 Mayo | 13 | 21 | 34 |
| 2016 Abril | 17 | 13 | 30 |
| 2016 Marzo | 11 | 18 | 29 |
| 2016 Febrero | 6 | 13 | 19 |
| 2016 Enero | 13 | 2 | 15 |
| 2015 Diciembre | 14 | 6 | 20 |
| 2015 Noviembre | 7 | 8 | 15 |
| 2015 Octubre | 13 | 13 | 26 |
| 2015 Septiembre | 15 | 20 | 35 |
| 2015 Agosto | 8 | 3 | 11 |
| 2015 Julio | 26 | 8 | 34 |
| 2015 Junio | 27 | 9 | 36 |
| 2015 Mayo | 37 | 15 | 52 |
| 2015 Abril | 26 | 12 | 38 |
| 2015 Marzo | 27 | 4 | 31 |
| 2015 Febrero | 28 | 5 | 33 |
| 2015 Enero | 19 | 2 | 21 |
| 2014 Diciembre | 29 | 4 | 33 |
| 2014 Noviembre | 23 | 7 | 30 |
| 2014 Octubre | 28 | 2 | 30 |
| 2014 Septiembre | 21 | 5 | 26 |
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