Characteristics, Natural Course and Treatment of Intramuscular Capillary-type Haemangioma: A Systematic Literature Review

Intramuscular capillary-type haemangiomas (ICTH) are rare vascular anomalies that can easily be misdiagnosed as other entities. A systematic review was performed of all cases of ICTH in the literature since its first description in 1972. An adjudication committee reviewed cases to include only ICTHs. Among 1,143 reports screened, 43 were included, involving 75 patients. The most frequent differential diagnosis was intramuscular venous malformations. The mean age of patients at diagnosis was 21.2 years. ICTH was mainly described as a gradually increasing mass (81.8%), painless (73.9%), that could occur anywhere in the body but most frequently on the head and neck (44.0%). Magnetic resonance imaging (MRI) was mainly used for diagnosis (69.1%) and displayed specific features. The most frequent treatment was complete surgical removal (73.9%), which could be preceded by embolization, and led to complete remission without recurrence in all but 1 case.

Utility of manual venous compression during transvenous Onyx injection for a scalp arteriovenous fistula: illustrative case

BACKGROUND

When performing transvenous liquid embolization for scalp arteriovenous fistulas, multiple networks of venous drainage could limit effective retrograde penetration of embolic agents into feeding arteries, resulting in incomplete obliteration. A salvage technique to achieve effective Onyx penetration with manual venous compression during transvenous embolization is demonstrated.

OBSERVATIONS

A 43-year-old man presented with a progressively enlarging mass on his left temporal scalp that was first noticed approximately 20 years earlier. External carotid artery injection showed two scalp arteriovenous fistulas (AVFs). The patient received endovascular embolization. After successful transarterial obliteration of one AVF, transvenous Onyx embolization was performed for another AVF located in the subcutaneous layer. To avoid unnecessary Onyx migration into multiple venous networks, several coils were put in a venous pouch as a scaffold for the Onyx, and feeding arteries were temporarily occluded. Despite these adjunctive techniques, the Onyx migrated into multiple veins and even toward the orbit without complete fistula obliteration. Thereafter, Onyx was injected under manual compression of venous outlets from the pouch, resulting in complete obliteration.

LESSONS

Manual compression of venous outlets can be used as a salvage procedure during transvenous Onyx embolization for a scalp AVF. A surgeon’s radiation exposure can be reduced by step-by-step adjunctive procedures.

Contemporary management of scalp cirsoid aneurysm: A dual-trained neurosurgeon's perspective

OBJECTIVE

Scalp cirsoid aneurysms are subcutaneous arteriovenous fistulae fed by branches of the external carotid artery. They present with progressive scalp swelling and cosmetic deformities in addition to neuro-vascular symptoms. We evaluate the treatment and outcome of this rare vascular lesion with surgery and adjunctive endovascular embolisation performed by a dual-trained neurosurgeon.

METHODS

A retrospective analysis of 6 cases operated over a 16 year-period was performed which comprised of clinical data, radiology including angiography and pre-operative embolisation, surgical approaches, outcomes and complications.

RESULTS

6 patients with ages ranging between 26 and 51 years were operated in the study period. All the patients underwent surgical excision of the lesion, of which 2 had undergone pre-operative embolisation of the feeders. There was no recurrence in the follow-up period (Mean 4.7 years) following total excision of the lesions. One patient had post-operative wound dehiscence and another had migration of embolic material to lungs.

CONCLUSION

Surgery is the predominant treatment method for scalp cirsoid aneurysms. Various adjunctive endovascular procedures can be performed pre-operatively to minimise operative blood loss.Though lower recurrence is seen with surgery for the scalp AV fistula, embolisation performed in select cases can achieve curative results with appropriate techniques.