Giant scalp arteriovenous malformation

Endovascular treatment for scalp arteriovenous fistulas: prospects and dilemmas

Scalp arteriovenous fistula (AVF) is an anomalous arteriovenous connection without a capillary bed. For symptomatic scalp AVFs, an appropriate treatment must be chosen. Currently, endovascular treatment (EVT) can serve as an alternative to surgical excision. However, EVT of scalp AVFs constitutes a challenge. A standard EVT strategy for scalp AVFs has not yet been established. Therefore, a review of current research on EVT for scalp AVFs is essential. In this review, the following issues were discussed: scalp vessel anatomy; etiology, angioarchitecture and classification of scalp AVFs; EVT principles and techniques; and EVT complications and prognosis. In addition, we attempted to propose a feasible grading system with 4 grades. Based on the literature review and our experience, we found that scalp AVFs have a complex angioarchitecture, which made EVT only possible in specific cases with low-grade scalp AVFs. EVT can be performed by transarterial or transvenous embolization. Direct puncture embolization can also be used for scalp AVFs. Complete occlusion of scalp AVF by EVT had low complication and recurrence rates and a good prognosis.

Parieto-occipital scalp arteriovenous malformation with drainage into the posterior superior sagittal sinus: A case report

This case report presents the unique clinical presentation of an 18-year-old female patient with an 8-year history of a progressively enlarging pulsatile mass in the left parieto-occipital region of her scalp. Remarkably, there was no history of trauma, headache, or other associated neurological deficits. Advanced imaging techniques, including computed tomography angiography and magnetic resonance imaging, revealed a vascular lesion consistent with an arteriovenous malformation beneath the scalp. Notably, the arteriovenous malformation's nidus was primarily supplied by branches of bilateral superficial temporal and occipital arteries, with a more pronounced involvement on the left side. Further magnetic resonance imaging characterization confirmed the diagnosis as a high parieto-occipital arteriovenous malformation/dural arteriovenous fistula. This case underscores the importance of a multidisciplinary approach involving neurosurgery and interventional radiology to the diagnosis and management of complex vascular lesions, particularly when they occur in unusual anatomical locations, like in our patient. The long-term clinical course and outcomes of such cases warrant continued investigation.

A Rare Case of Scalp Arteriovenous Malformation in an Adolescent Patient

Scalp arteriovenous malformations (AVMs) are rare lesions that arise due to a pathological fistulous connection between scalp arterial feeders and draining veins without the involvement of capillary beds. Here, we report a case of a 17-year-old male who presented with an enlarging, pulsatile, mass in the scalp of the parietal region with mild headaches and was diagnosed with a scalp AVM that was treated successfully with endovascular trans-arterial embolization. Scalp AVMs are uncommon extracranial vascular abnormalities that neurosurgeons hardly ever see. To precisely define the angiographic architecture of an AVM and to organize further management, digital subtraction angiography is crucial.

Medusa's Wrath: Bleeding Giant Scalp Arteriovenous Malformation in an Adult: A Case Report

BACKGROUND

Scalp arteriovenous malformation (AVM) is a rare congenital disease that may present with massive bleeding. To date, surgical excision remains the definitive management. However, the procedure could lead to intraoperative bleeding due to the tumor's high blood flow and complex vascularity.

CASE REPORT

A 49-year old Filipino male presented with a bleeding giant scalp AVM. Computed tomographic scan and duplex studies showed multiple feeding vessels with turbulent flow arising primarily from the right superficial temporal, right posterior auricular, and occipital vessels. Prior to surgery, the patient underwent transfusion due to preoperative hemoglobin of 6 g/dL. Proximal control of the right external carotid artery was performed through a supine position and left in place to reduce the majority of blood flow to the AVM. The patient was turned to a prone position for surgical planning to achieve maximal skin-sparing dissection prior to excision. First, ligation of bilateral superficial temporal and posterior auricular arteries was performed. Next, excision above the periosteum with segmental ligation of feeding vessels around the AVM was carried out. Reconstruction of the defect was done via scalp advancement flap and split-thickness skin grafting. Intraoperative blood loss was 1.6 L. On the sixth postoperative day, the patient was discharged with 100% graft take.

CONCLUSION

Management of scalp AV malformation is challenging, and despite measures to decrease intraoperative bleeding, blood loss is still high. While preoperative embolization has been reported to decrease the risk of bleeding, this procedure is not currently available in our setting. Our case highlights the complexity of giant scalp AV malformation management in a limited-resource setting. Even in the absence of endovascular intervention, outright surgical excision of AVM can be performed, albeit with higher levels of blood loss.

Case report: Endovascular treatment of two scalp arteriovenous malformation cases via direct percutaneous catheterization: A case series

Background

Scalp arteriovenous malformations (AVM) are rare vascular malformations reported only in small case series. Scalp AVMs usually present with symptoms, including headache, tinnitus, epilepsy, cerebral ischemia, and necrosis of the scalp, which can cause functional, cosmetic, and psychological problems. There are many difficulties in the treatment of scalp AVM because of its complex characteristics of vascular anatomy, non-uniform structure, and intracranial-extracranial anastomosis.

Case description

To illustrate the endovascular treatment of scalp AVM via direct percutaneous puncture while traditional arterial and venous approaches were not available. In this report, access was obtained through a direct puncture of the enlarged frontal vein. Onyx-18 was injected through a microcatheter to occlude draining veins, fistulous connection, and the feeders. An 18-gauge indwelling needle was inserted into draining veins directly. Postembolization angiography demonstrated complete sAVM occlusion immediately and no non-targeted embolization. At a 1-year follow-up, no procedure-related complications and evidence of recurrence were observed.

Conclusion

The technique of endovascular embolization via direct percutaneous puncture approach is safe, rapid, and effective for specific sAVM. Treatment options should be made in terms of size, vascular anatomical characteristics of the lesions, patient's preference, cosmetic factors, and available expertise.

Combined Treatment of High-Flow Scalp Arteriovenous Malformations

INTRODUCTION

Appropriate treatment of scalp arteriovenous malformations (SAVMs) remains largely unclear given the rarity of reported cases. This single-institution case series presents consecutive patients with extracranial SAVMs and long-term follow up.The primary aim of this study was to review treatment decisions, evaluate clinical outcomes, and compare our experience to available literature in order to better understand SAVMs and improve future outcomes.

MATERIALS AND METHODS

A retrospective review of consecutive patients with extracranial SAVMs between January 2015 and December 2019 was performed. Treatment factors of interest included embolization method, embolic agents, and decision to proceed with surgical resection. Relevant clinical outcomes included recurrence rates, cure rates, and complications.

RESULTS

Seven patients were included in the present series. Satisfactory outcomes were ultimately achieved for all 7 patients using embolization with or without combined surgical resection. Embolizations performed in combination with resection were curative in 4 of 4 cases (100%). Embolizations performed without resection were curative in 0 of 4 cases (0%), satisfactory in 2 of 4 cases (50%), and unsatisfactory in 2 of 4 cases (50%).

DISCUSSION

All SAVM patients in this series were treated satisfactorily using embolization with or without operative resection. This study strongly suggests that embolization combined with surgical resection during the same admission yields the best treatment outcomes for SAVMs, specifically demonstrating lower rates of recurrence and embolization-related complications. Decisions on whether or not to proceed with resection should be made by the interventional radiologist, the plastic surgeon, and the patient together.

Treatment of a Scalp Arteriovenous Malformation by a Combination of Embolization and Surgical Removal

BACKGROUND

Scalp arteriovenous malformation is a rare disease. In terms of treatment, surgical removal is often effective and performed. With the development of endovascular treatments, a combination of surgical removal and embolization is now often performed.

CASE DESCRIPTION

A 44-year-old man presented with a mass in his left occipital region. Cerebral angiography led to a diagnosis of scalp arteriovenous malformation. Although he had no neurologic deficits, perfusion computed tomography (CT) scan showed a slight decrease in blood flow in the left cerebral hemisphere, which was presumed to have been caused by the scalp arteriovenous malformation. He suffered from a sleep disorder caused by tinnitus, and a discomfort with the lesion itself; therefore, we decided to surgically remove the lesion. To suppress intraoperative bleeding and safely perform the surgery, preoperative embolization was also planned. After treatment, he had no neurologic deficits and the sleep disorder improved. Perfusion CT scan performed after the surgery showed an improvement in cerebral blood flow in the left cerebral hemisphere.

CONCLUSIONS

Because cerebral blood flow may decrease depending on the progression of the lesion, the cerebral blood flow should be evaluated. Considering the treatment modalities depending on the lesion can provide treatment with less recurrence and higher patient satisfaction.

Scalp Cirsoid Aneurysms: Case Illustration and Systematic Review of Literature

BACKGROUND

Scalp cirsoid aneurysms are rare subcutaneous arteriovenous fistulae affecting the scalp. They can be easily misdiagnosed and mistreated.

OBJECTIVE

To review reported cases of scalp cirsoid aneurysms for their incidence, etiology, clinical presentation, treatment, and outcomes using an illustrative case.

METHODS

We conducted a PUBMED, SCOPUS, OVID SP, SciELO, and INFORMA search using the keywords; “cirsoid,” “aneurysm,” “arteriovenous,” “malformation,” “scalp,” “vascular,” and “fistula.” We identified 74 pertinent papers, reporting 242 cases in addition to our reported index case.

RESULTS

Median age at presentation was 25 yr (range 1-72 yr); male to female ratio was 2.5:1. The most common symptoms were a pulsatile mass (94% of patients), headaches (25%), and tinnitus (20%). The median duration of symptoms was 3 yr (6 d to 31 yr), with 60.2% occurring spontaneously, 32.23% traumatic, and the rest iatrogenic. A total of 58.5% of cases were managed with surgical excision only, 21.6% with endovascular embolization only, and 14.5% with a combination of both methods. The complication rate observed in the endovascular embolization treatment cohort (55.8%) was significantly higher than that observed in the surgical excision only cohort (9.9%) (P < .00001) and in the combined therapy cohort (0%) (P < .00001). There is a low recurrence rate after treatment irrespective of modality: surgical excision only (6.3%), endovascular embolization only (8.3%), and combined therapy (0%).

CONCLUSION

Scalp cirsoid aneurysms are associated with good prognoses when recognized and managed appropriately. We suggest combining surgery with endovascular embolization as the optimum treatment modality.