Scalp Arteriovenous Malformation Resection With Novel Technique of Endovascular and Surgical Devascularization

Abstract

A 26-year-old female patient referred to our emergency service with complaint of increase headache and swelling of the left upper eye led. External examination of the head revealed left frontal scalp and left eye led swelling, which was soft and pulsatile. Brain computed tomography (CT) scan and magnetic resonance imaging showed left frontal soft tissue and left periorbital swelling with crowded left intraorbital contents. Brain CT angiography showed vascular mass lesion in the left frontal subcutaneous lesion. Six-vessel cerebral angiography showed left frontal scalp arteriovenous malformation (AVM) supplied from the right and left superficial temporal arteries from the external carotid artery and from the left supraorbital artery arising from the ophthalmic artery of the internal carotid artery. By endovascular technique, bilateral superficial temporal arteries were occluded with Onyx 18 (Micro-Therapeutics, Inc., Irvine, CA). The patient was operated after 2 days. Left eye-brow incision was performed and the supraorbital artery was exposed, ligated, and cut. Left fronto-temporal skin incision was performed and the AVM totally excised. No intraoperative nor postoperative complications seen. Follow-up cerebral angiography showed total resection of the AVM.

The role of combined computed tomographic angiography and digital subtraction angiography in the management of cervico-facial vascular lesions

“…Alawneh et al [20] mentioned the most frequent sites of involvement in scalp AVMs were the frontal, temporal, and parietal regions. The origin of the main feeder is in the subcutaneous tissue of the scalp which originates from the ECA where the superficial temporal artery is most frequently involved one.…”

Surgical management of scalp cirsoid aneurysms: Kuwait experience. (case series)

“…Its lower rate of complications and recurrence, effective and immediate resolution of symptoms, cost-effectivity, and satisfying cosmetic outcomes allows the surgical approach to be a convenient and appropriate [ 3 , 5 , 7 , 13 , 14 ]. Perioperative bleeding, necrosis, infection, and recurrence following incomplete resection are the most common complications of surgical intervention [ 2 , 3 , 6 , 15 ]. Initial ligation of all feeding arteries and complete resection showed to minimize intraoperative bleeding and produce satisfactory outcomes [ 5 ].…”

Post-traumatic arteriovenous malformation of the superficial temporal artery

“…1,4 Conventional angiography is the investigation of choice however, computed tomography or magnetic resonance angiogram are the noninvasive alternatives for outlining anatomy and excluding organ involvement. 1,2,6 These can also be diagnosed less definitively by ultrasound with Doppler. Magnetic resonance imaging offers a more distinct analysis of the adjacent soft tissue structures such as muscles, nerves, tendons, bones, and solid organs.…”

“…1,4,7,12 A study by Visser et al 13 in 2011 showed an overall recurrence rate of 8.7%, the greatest risk factor of which is incomplete excision. 2 The gold standard of management has traditionally involved surgical excision of the lesion followed by reconstructive surgery as indicated. 3,13 However, less invasive interventions such as endovascular coil embolization, sclerotherapy, and electrothrombosis and ligation of the feeder vessels may be preferred.…”

“…1,3,14,15 Although highly effective, limitations of these endovascular techniques include recanalization or recruitment of other external carotid branches; delayed resolution of the mass systemic; thrombin effects with thrombin embolization; and ischemia with endovascular coiling. 2,3,14 A retrospective study by Do et al 16 evaluated ethanol embolization in 175 patients and demonstrated a 40% complete cure, 18% persistence, and 2% worsening of symptoms. This was associated with a 52% overall complication rate.…”