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MRI showed a predominantly cystic lesion in the midline posterior fossa, with a compressive mass effect. Subsequently, she underwent a suboccipital craniotomy for microscopic resection of a posterior cranial fossa lesion. Histopathology reported keratin flakes with severe active inflammation, and foreign body type giant cell reaction in scalp excision with free hair shafts through the inflammatory focus, consistent with pilonidal sinus. 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