Intraosseous venous malformation of the mandible: a review on interdisciplinary differences in diagnostic nomenclature for vascular anomalies in bone and report of a case

Endovascular embolisation of a complex mandibular AVM: a hybrid transarterial and transvenous approach

Mandibular arteriovenous malformations (AVMs) are rare lesions which can present with life-threatening haemorrhage. Endovascular embolisation can be life saving for these patients. We discuss a patient of mandibular AVM, who initially presented with reports of massive oral bleeding. The lesion was only partially embolised via transarterial route, as the nidus could not be penetrated completely. In view of rebleeding within 72 hours from the same site, a second embolisation procedure was done via combined, transarterial and transvenous approaches. Coils and onyx were used as embolising agents. Complete embolisation was achieved via combined approach. No further bleeding episodes were seen at 1-year follow-up. Endovascular embolisation of mandibular AVMs can be technically challenging and, hence, a sound knowledge of the anatomy as well as the possible modification of technique is essential to achieve complete obliteration of the lesion and to maximise the benefit of embolisation and to avoid major radical surgery.

Intraosseous Venous Malformations of the Head and Neck

Intraosseous venous malformations represent a subtype of venous vascular malformations that arise primarily in bone. In the head and neck, intraosseous venous malformations are most frequently found in the skull, skull base, and facial skeleton, with location at the geniculate ganglion of the facial nerve perhaps the most widely recognized. These non-neoplastic lesions are characterized by dilated venous channels with characteristic internal bony spicules on CT but may present with a more complex appearance on MR imaging and may share features with more aggressive lesions. Further confounding the imaging-based diagnosis of intraosseous venous malformation is the frequent misrepresentation of these lesions as hemangiomas in the radiology and clinical literature, as well as in daily practice. Because most intraosseous venous malformations can be left alone, their correct diagnosis may spare a patient unnecessary concern and intervention.

Imaging of benign cervicofacial vascular anomalies and associated syndromes

Cervicofacial vascular anomalies can result in morbidity, pain, and cosmetic concerns in affected individuals. Each anomaly has its own unique natural history, treatment, and associations with underlying genetic syndromes. For optimal patient care, it is important for the neuroradiologist to accurately recognize and characterize these entities to ensure appropriate treatment and management. In this review, we discuss the general characteristics, classifications, and imaging features associated with the most common vascular anomalies such as hemangiomas, arteriovenous malformations and fistulas, capillary malformations, venous malformations, and lymphatic malformations in the context of associated syndromes. Additionally, we discuss novel imaging techniques that aid in identifying these vascular anomalies.

Mandibular Fracture as First Sign of an Occult Intraosseous Hemangioma

Intraosseous hemangioma (IH) in the maxillofacial area is a very uncommon neoplasm. Here, the authors show an exceptional case not previously reported in the literature of a 65-year-old man who presented with a pathological mandibular fracture following a facial trauma that was the first sign of an occult cavernous IH. Complete excision of the tumor in the mandibular ramus reduced the risk of severe bleeding and prevented long-term recurrence, whereas immobilization of the fracture obtained an excellent functional result. This clinical report highlights the possibility that a previously unknown primary IH may debut as a pathological fracture and the importance of differential diagnosis in this location.

Retrograde transvenous balloon-assisted Onyx embolization of mandibular arteriovenous malformation after hemorrhage

Mandibular arteriovenous malformation (AVM) is a rare lesion, but it often can be presented with life-threatening bleedings. Endovascular treatment of mandibular AVMs has multiple approaches including transarterial embolization, transvenous embolization, direct puncture, and sclerotherapy. In this case study, we present a patient with mandibular AVM complicated by hemorrhage. The patient was treated with transarterial embolization, followed by transvenous sclerotherapy with balloon occlusion of venous outflow. But radical occlusion of AVM was achieved only by transvenous embolization of AVM with Onyx via double lumen balloon, which occluded the venous outflow.

Embolization as the Primary Treatment for Mandibular Arteriovenous Malformations: An Analysis of 50 Literature Reports and of an Illustrative Case

PURPOSE

The aim of the present report is to describe 50 cases in the literature of mandibular arteriovenous malformations (AVMs) in which embolization was the primary treatment and to discuss details such as age, gender, materials used, outcome of embolization, time of follow-up, and intra- or postprocedure complications. An illustrative case in which reossification was noticed after embolization also is presented.

PATIENTS AND METHODS

The study was carried out in 2 steps. In the first, an electronic search without time restriction for embolization as the primary treatment for mandibular AVMs was performed on Medline through PubMed. In the second, the case of a patient with mandibular AVM and massive oral bleeding episodes is described after a long-term follow-up.

RESULTS

Clinical stability with the cessation of oral bleeding episodes was detected in 25 cases and 2 cases were planned for another embolization session. Clinical stability and reossification were detected in 23 of the 50 cases included. Complications were reported in 50% of cases, but most were minor and transient.

CONCLUSION

Currently, owing to more sophisticated imaging techniques, the diagnosis of mandibular AVMs is quicker and new, less invasive techniques that avoid surgical resection have proved effective. It should be emphasized that these techniques are not without complications and that long-term monitoring is extremely important.

A case series of intraosseous hemangioma of the jaws: Various presentations of a rare entity

Background

Hemangiomas of the soft tissue are common in the head and neck area, especially in the tongue and in children under ten years of age. Intraosseous hemangiomas of the mandible and maxilla (IHM), on the other hand, are exceedingly rare and are not well characterized. This study presents six IHM cases focusing on the clinical, radiographic, and histologic characteristics.

Material and Methods

Six cases of IHM were retrieved from the archives of the Biopsy Services at the University of Washington. Clinical, radiologic, and histologic findings are described.

Results

A total of six cases of IHM were reviewed. The patient age range was 16 to 65; the group comprised three females and three males. All six cases presented as swellings, two caused tooth resorption, and one was associated with pain and numbness. Three of the six IHM were present in the body of the mandible, two in the area of the extracted right mandibular third molar, and one in the anterior maxilla between the right canine and lateral incisor. Radiographically, five were radiolucent and one was radiopaque. Of the five radiolucent, two were unilocular and three multilocular. The one radiopaque case was exophytic, simulating a large osteoma. Histologic features ranged from cavernous to a mix of venous and arterial types. Follow-up is available for all six cases ranging between one to seven years; only one case recurred within the first year post-surgery.

Conclusions

IHM are exceedingly rare; IHM do not present in a consistent manner both clinically and radiographically. It is therefore important to recognize the wide spectrum of IHM's clinical, radiographic, and histological presentations. Key words:Hemangioma, Vascular Malformation, mandible, maxilla.

Immunohistochemical and histochemical characterization of intraosseous arteriovenous malformations of the jaws: analysis of 16 cases with emphasis on GLUT-1 immunophenotype

OBJECTIVES

Intraosseous vascular lesions of the craniofacial region are rare and may cause diagnostic and therapeutic challenges. The purpose of this study was to characterize 16 cases of intraosseous arteriovenous malformations (AVMs) affecting the jaws.

STUDY DESIGN

Immunohistochemical evaluation was performed using antibodies against α-smooth muscle actin (α-SMA), desmin, CD31, D2-40, and glucose transporter 1 (GLUT-1). Staining with elastic Verhoeff-Van Gieson and Masson trichrome histochemical stains was also performed.

RESULTS

No gender predilection (female:male ratio = 1:1) was observed, with patients' mean age being 50.8 years (SD of ±13.9; range 28-71 years). Predilection for the mandible was observed (12 of 16 [75%]). Immunohistochemically, diffuse endothelial CD31 staining was noted, and α-SMA strongly highlighted smooth muscle cells and pericytes. Desmin-positive vessels were identified in 9 of 16 AVMs (56.3%). D2-40 was uniformly negative in all specimens. AVMs were negative for GLUT-1 (11 of 14 [78.6%]) except for 2 cases (2 of 14 [14.3%]) exhibiting focal limited cytoplasmic GLUT-1 immunoreactivity. One case was equivocal for GLUT-1. Masson trichrome highlighted smooth muscle cells, and elastic fibers were identified in thick-walled arteries.

CONCLUSIONS

AVMs of the jaws generally lack expression of GLUT-1, similar to soft tissue vascular malformations. Clinicoradiographic features of intraosseous AVMs in the present study were consistent with the findings of previous studies, although mean age was higher.

Mandibule rehabilitation after embolization of hemangioma with implant overdenture using existing endosseous implants: A clinical report

PATIENT

A fifty-year-old man received embolization for mandibular hemangioma two years ago, and the surgeon had placed four implants in his mandible and made a removable denture upon the implants. His denture however fractured repeatedly in the past years. After examination and communication with the patient, an implant-assisted overdenture incorporating bar attachment combined ERA attachment and Locator abutment was re-fabricated. A sixteen months follow-up showed acceptable outcome.

DISCUSSION

There are some guidelines on design of implant over-denture, the site of implant will affect the final result. The unfavorable bone structure of mandibular hemangioma restricts the number and the site of implant, modification of design is essential to improve the final result.

CONCLUSION

Multi-disciplinary cooperation should be established for extensive edentulous case. Overlay type prosthesis incorporating several types of attachments can be suitable for complex case because of acceptable results and easy maintenance.

Focal Benign Disorders of the Pediatric Mandible With Radiologic-Histopathologic Correlation: Mandibular Development and Lucent Lesions

OBJECTIVE

Lucent lesions of the pediatric mandible may present variably. Cysts, neoplasms, and developmental and inflammatory conditions have a host of possible causes. There is also substantial overlap in the imaging appearance of cysts and that of benign but locally aggressive tumors that need to undergo resection.

CONCLUSION

The purpose of this article is to present common and uncommon lucent lesions of the mandible in children, with an emphasis on benign abnormalities. Discussions of imaging and histopathologic features are provided.

Management of Intraosseous Vascular Malformations of the Jaws in Children and Adolescents: Report of 6 Cases and Literature Review

Background

Intraosseous vascular malformations represent a rare clinical entity of the facial skeleton. The purpose of the current study was to present our experience in a Greek paediatric population and propose guidelines for the treatment of these jaws anomalies in children and adolescents.

Methods

A retrospective study (from 2009 to 2014) was performed to investigate the features and management of the intraosseous vascular anomalies in a Greek paediatric population.

Results

Six patients aged between 6 and 14 years were treated for intraosseous vascular malformations (4 venous and 2 arteriovenous) of the jaws. Five lesions were located in the mandible and one in the maxilla. In four lesions with pronounced vascularity superselective angiography, followed by embolization was performed. Individualized surgical treatment, depending on the size and vascularity of the lesions was applied in 4 patients.

Conclusions

The intraosseous vascular malformations of the jaws may escape diagnosis in paediatric patients. A multidisciplinary approach is important for their safe and efficient treatment. Embolization is recommended for extended high-flow lesions, either preoperatively or as a first-line treatment, when surgery is not feasible without significant morbidity.

Intraosseous venous malformation of the zygoma: A case report and literature review

INTRODUCTION

Venous malformations of the zygoma are rare. Historically, venous malformations have been misrepresented as "hemangiomas". The International Society for the Study of Vascular Anomaly (ISSVA) classification is a reasonable classification that leads to appropriate clinical diagnosis and treatment strategies. Collaboration between surgeons, radiologists, and pathologists is necessary for accurate diagnosis and management.

PRESENTATION OF CASE

We present here a case of an IOVM in a 59-year-old woman who was treated with a multidisciplinary approach. Superselective arteriography and embolization were effective for diagnosis as well as for prevention of large hemorrhage during surgery. En-bloc resection of the zygoma was performed within hours after embolization and autologous calvarial bone graft was used for primary reconstruction.

DISCUSSION

We performed a literature review consisting of reviewing 52 cases of IOVM of the zygoma discussing optimal material for reconstruction of the defect for intraosseous venous malformation of the zygoma nationally and internationally.

CONCLUSION

The combination of surgery and preoperative angiography makes it possible to prevent high risk of hemorrhage. For primary reconstruction of the zygoma, use of autologous calvarial bone can maintain the volume and reconstruct the natural malar contour.

An unusual case of intraosseous vascular malformation of the maxilla mimicking fibrous dysplasia: a case report and literature review on imaging features of intraosseous vascular anomalies of the jaw

Intraosseous vascular malformation (IVM) is a relatively rare pathological condition that may pose significant risks, such as excessive bleeding, during surgical procedures. We present a case of an 18-year-old female patient with firm swelling in the left maxilla. A bony expansion over the left half of the maxilla with preservation of the outer cortex and a ground glass appearance on CT images initially revealed a possibility of fibrous dysplasia. However, a tentative diagnosis of IVM was made based on the vascular nature of the lesion as well as the patient's surgical history and additional imaging findings. IVM should be included in the differential diagnosis of an expansile bony lesion with trabecular alteration. Through the literature review, it was found that imaging findings, such as a neurovascular canal widening on CT images and a hyperintense signal on T1 weighted MR images, might be helpful in differentiating IVM from other pathologies.

Diverse imaging characteristics of a mandibular intraosseous vascular lesion

Intraosseous vascular lesions of the maxillofacial region are rare, and the differential diagnosis of intraosseous vascular malformations from other jaw lesions can be challenging. In the present case, magnetic resonance imaging and three-dimensional computed tomographic angiography (CTA) was used for diagnosis, and the lesion was treated wih surgical excision. Diverse characteristics such as the "honeycomb" and "sunburst" radiographic appearances and the absence of major peripheral feeder vessels in the CTA were noted. Intraosseous vascular malformations have a varied radiographic appearance, and the nomenclature of these lesions is equally diverse, with several overlapping terms. Pathologists do not generally differentiate among intraosseous vascular lesions on the basis of histopathology, although these lesions may present with contrasting immunohistochemical and clinical behaviors requiring varied treatment strategies. This case report highlights the need for multiple imaging modalities to differentiate among vascular lesions, as well as to better understand the behaviors of these unique lesions.

Transarterial embolization of mandibular arteriovenous malformations using ONYX

PURPOSE

To document the efficacy of ethylene vinyl alcohol copolymer (ONYX; ev3/Covidien, Irvine, CA) in the treatment of arteriovenous malformations (AVMs) of the mandible.

MATERIALS AND METHODS

A retrospective consecutive series of patients with facial AVMs isolated to the mandible and immediate perimandibular tissue was identified at 2 institutions. The primary treatment modality of transarterial embolization using ONYX was performed by way of the external carotid artery branches. Staged procedures were accomplished until no arteriovenous shunt remained. A 1-year follow-up angiogram was obtained for each patient.

RESULTS

Three patients, aged 8 (patient 1), 16 (patient 2), and 17 (patient 3) years presented with bleeding from facial AVMs isolated to the mandible. Patient 1 was female and patients 2 and 3 were male. The 2 older patients had loose molar or canine dentition. Transarterial embolization with ONYX achieved complete angiographic closure of the arteriovenous shunt in each patient. A total of 1, 6, and 3 staged embolization procedures were performed in the 3 patients. Patient 2 had mild transient facial numbness after embolization that completely resolved. Patient 3 had loose molars associated with the AVM that were extracted for treatment of intraprocedural bleeding. The 1-year angiographic follow-up data demonstrated durable closure of all 3 lesions.

CONCLUSIONS

Transarterial embolization of high-flow intraosseus mandibular AVMs was safely accomplished with ONYX in our small retrospective cohort. Complete, durable occlusion was found on the angiogram at 1 year, with clinical stability extending to an average of 3 years. Surgical resection of the AVM was avoided in all 3 patients.