Combined Preoperative Endovascular Embolization and Surgical Excision for Scalp Arteriovenous Malformations: A Systematic Review and Case Illustration

OBJECTIVE

To evaluate the efficacy of the combined approach of preoperative endovascular embolization (EE) and surgical excision (SE) for scalp arteriovenous malformation (AVM) and present an illustrative case report.

METHODS

A systematic review was conducted using online databases (PubMed/Medline, Cochrane, and Embase) on February 15, 2023. The inclusion criteria were any type of study of patients with scalp AVMs who were diagnosed and confirmed through angiography and treated with combined preoperative EE and SE. All the articles that met the inclusion criteria were included in this study.

RESULTS

A total of 49 articles (91 patients) were included. The patients' age ranged from 10 days to 70 years at the time of presentation. The most common symptoms were a pulsatile mass in 51 patients (56.04%), progressively growing mass in 31 patients (34.06%), and bruits and/or thrills in 22 patients (24.17%). Complications of preoperative EE and SE were observed in only 5 patients; 3 patients (3.29%) had harvested skin graft marginal necrosis, 1 patient (1.09%) had skin necrosis, and 1 patient (1.09%) had a wound infection. Only 2 patients (2.19%) reported a recurrent or residual mass during a median follow-up period of 12 months.

CONCLUSIONS

The management of scalp AVMs can be challenging; therefore, focused, and accurate identification of the complexity of the vascular anatomy is required. The combined method of preoperative EE and SE showed satisfactory outcomes with low rates of complications and recurrence; thus, we recommend this approach for the management of scalp AVMs.

Hybrid Endovascular and Surgical Treatment of a Traumatic Scalp Arteriovenous Fistula

Traumatic scalp arteriovenous fistula (AVF) is a relatively rare complication of scalp trauma. Patients most commonly present with a growing pulsatile head mass. History of trauma, clinical presentation, and diagnostic imaging, including digital subtraction angiography, aid in establishing the diagnosis. Endovascular embolization is the preferred treatment modality which may be combined with surgical excision for larger complex lesions. In this case, we report the clinical and radiological features of a traumatic scalp AVF in a middle-aged man with a remote history of trauma that was treated with a two-step hybrid approach combining transarterial embolization with surgical resection. We also present a brief overview of the various treatment modalities currently employed to treat scalp AVFs.

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.

Traumatic scalp arteriovenous fistula post capillary implantation successfully treated using PHIL embolic agent

Background

A traumatic arteriovenous fistula of the scalp due to hair transplantation (AVFHT) is a rare fistulous communication between branches of the arteries and draining veins in the scalp's subcutaneous tissue. Its incidence is unknown and its clinical manifestations may range from a pulsatile mass to seldom epilepsy. Surgery and interventional approaches (percutaneous and endovascular embolization) using coils and embolic agents such as Onyx have been used as treatment options. The authors report a rare case of an AVFHT successfully treated through percutaneous and endovascular embolization using coils and precipitating hydrophobic injectable liquid (PHIL) embolic agent. This is possibly the first reported case using PHIL embolic agent to treat an AVFHT.

Case Description

The patient presented with a painful and disabling scalp swelling in the right parieto-occipital region 2 years after a hair transplant in 2011. A computed tomography angiography showed an arteriovenous fistula between branches of the right superficial temporal artery and branches of the right occipital artery to the right superficial temporal vein that was successfully embolized using coils and PHIL. The patient was discharged after a smooth recovery and 1 month later remained healthy.

Conclusion

Percutaneous and endovascular embolization using PHIL embolic agent can be an alternative treatment for AVFHT.

Cirsoid Aneurysm of Occipital Artery-Rare of the Rarest

A case of 33 year old man diagnosed with a rare case of Cirsoid aneurysm of occipital artery was treated under general anaesthesia for surgical excision. An interdisciplinary approach of Neurosurgery and Oral and Maxillofacial team was made. Here we have discussed the clinical steps performed in the management of Cirsoid aneurysm of occipital artery. In-toto excision and thorough follow up has uneventfully lead to success in the outcome.

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.

A puzzling case of Multiple asymptomatic nodules over scalp - a case report

Cirsoid aneurysms (CAs) of the scalp are rare arteriovenous (AV) malformations presenting as nodular lesions over scalp. Depending on the size and intracranial extension, they can vary from asymptomatic lesions to being potentially lethal due to secondary haemorrhage. Being a vascular lesion, clinically misdiagnosed cases may lead to devastating outcome on any kind of diagnostic surgical intervention. Here we report a case of a 45-years-old lady presented with multiple papulonodular lesions over scalp, diagnosed as cirsoid aneurysm. This article is protected by copyright. All rights reserved.

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

Background

Cirsoid aneurysms are arteriovenous malformations of the scalp region that usually manifest as a painless pulsatile mass. These are present in the younger age group and frequently associated with trauma.

Objectives

Several treatment algorithms have been proposed, and we report our experience with sole surgical management.

Methods

Retrospective review of all the scalp vascular malformation cases performed in the main national Vascular Surgery Service of Kuwait. Pre-operative data, including patient demographics were obtained. All patients underwent diagnostic vascular Duplex ultrasound and angiography. Intra-operative and post-operative data, including outcomes and follow up were recorded.

Results

Six patients with Cirsoid aneurysm, four females and two males, had a mean age of 19.7 years (range, 10–33 years). All the patients presented with a painless pulsating mass in the scalp (4 Anterolateral and 2 posterior), and one case had associated dizziness and headache. These malformations were found to be solely fed by the extra-cranial vessels with no intra-cranial communication. One patient had pre-operative embolization prior to excision, and the rest had sole surgical excision. No postoperatively complications or recurrence were seen at 2–5 year follow up.

Conclusions

Cirsoid aneurysms are amenable to sole surgical excision with excellent results after excluding intra-cranial communication.

•

Cirsoid aneurysms are extra cranial AVMs arising in the scalp

•

Most patients present with painless mass.

•

Diagnosis is made with duplex ultrasound and/or CT angiography.

•

We recommend sole surgical over endovascular therapy or a hybrid approach.

Successful Use of Neurovascular Plug for Embolization of Scalp Arteriovenous Fistula: A Novel Technique

PURPOSE

We report a case of a pediatric patient developing a delayed-onset scalp arteriovenous fistula (AVF) and pseudoaneurysm managed with a new technique.

TECHNIQUE

A 10-year-old boy presented to the outpatient clinic complaining of a growing pulsatile mass in the right side of the skull after head trauma 6 months ago. He had no neurological deficits. Imaging studies revealed scalp AVF with pseudoaneurysm. The arterial feeding was from the right temporal artery, while the blood was drained into the superior sagittal sinus and the facial vein. The fistula was occluded successfully by a microvascular plug (MVP). Follow-up angiography 1 year later showed that the AVF was no longer seen with complete embolization of pseudoaneurysm, total occlusion of the abnormal vessels, and the absence of MVP migration.

CONCLUSION

To the best of our knowledge, we report the first case of successfully using MVP to treat scalp AVF. The MVP is a novel technique with its unique ability to achieve rapid, safe, effective, and permanent vascular occlusion through a single device. Besides, the possibility of delayed-onset traumatic vascular injuries should be considered in a patient with head or facial trauma.

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.

Delayed presentation of a traumatic scalp arteriovenous fistula

Background:

Arteriovenous (AV) fistulas of the scalp are extracranial vascular malformations commonly caused by trauma and typically present within 3 years. Although they follow a benign course, they can be esthetically displeasing.

Case Description:

We present an atypical onset of scalp AV fistula in a patient with a 1-year history of the left-sided pulsatile tinnitus and scalp swelling 7 years after a traumatic epidural hematoma evacuation. Our patient was found to have an 8 mm AV fistula supplied by the deep temporal artery. Endovascular embolization was performed using eight coils. There was no complication from the procedure, and the patient’s pulsatile tinnitus and swelling resolved immediately after embolization. Follow-up angiogram demonstrated complete obliteration of the AV fistula.

Conclusion:

Delayed presentation of traumatic scalp AV fistula is very rare, and it is important to keep this in the differential in patients with scalp swelling after head trauma.

Emergent Hybrid Treatment of a Ruptured Scalp Arteriovenous Fistula with Eyelid involvement: Technical Note

BACKGROUND

 Scalp arteriovenous fistulas (AVFs) are a rare vascular disease usually presenting as a progressively increasing pulsating mass in the scalp. These lesions can be associated with mild to severe complications, including congestive heart failure. If ruptures, this pathology constitutes a life-threatening medical emergency because of its potential to cause severe bleeding and acute anemia.

METHODS

 We describe the case of a young woman with a ruptured Yokouchi type C scalp AVF with eyelid involvement.

RESULTS

 The patient presented with hypovolemic shock and acute anemia due to severe bleeding from the lesion. Emergent treatment through a combined endovascular and open surgical approach was required to stop bleeding and stabilize the patient.

CONCLUSIONS

 Emergent and effective treatment is required to stop bleeding when a scalp AVF ruptures. A combination of endovascular embolization and microsurgical excision of the shunt is a treatment option.

Surgical Management of Cirsoid Aneurysms of the Scalp: Ten Years' Experience

OBJECTIVE

Cirsoid aneurysms are rare arteriovenous malformations of the scalp that present with disfigured pulsatile masses and may be associated with headache, bleeding, or tinnitus. These lesions are difficult to manage because of their complex vascular anatomy, high shunt flow, and cosmetic disfigurement; many options have been described to treat such lesions. We evaluate 10 years' experience in the surgical management of cirsoid aneurysms of the scalp.

METHODS

This study included 15 patients with cirsoid aneurysm of the scalp, all of whom were treated with surgical excision only over 10 years. They were 8 females and 7 males, with a median age of 23 years. History of trauma was present in 5 patients. Frontal and parietal regions were the commonly affected sites. Superficial temporal, supraorbital, and occipital arteries were the most frequent feeding arteries.

RESULTS

Excision of the lesion was performed in all patients using our modified surgical technique. All patients had good cosmetic results and there were no recurrences during an average follow-up of 25 months.

CONCLUSIONS

Despite great progress in endovascular therapy, surgical excision of cirsoid aneurysms of the scalp seems to be the most effective treatment, with good results and patient satisfaction.

The usefulness of temporary balloon occlusion during transarterial embolization for scalp arteriovenous fistula

Background:

We present two cases of scalp arteriovenous fistula (sAVF) treated by transarterial embolization with the aid of a temporary balloon occlusion (TBO) to detect precise vasculature.

Case Description:

Case 1: A 59-year-old woman noticed a sudden onset of pulsating bruits. sAVF was fed by the right superficial temporal artery (STA) and drained to the right superficial temporal vein. We performed feeder occlusion using coils after the recognition of a single feeder and a single fistula using TBO. Case 2: A 42-year-old woman noticed a pulsating subcutaneous mass. sAVF was fed by the right occipital artery (OA) and drained to the right occipital vein (OV). We could detect another feeder of the right STA after the TBO of the OA. We performed transarterial feeder occlusion for STA and OA using coil and N-butyl-2-cyanoacrylat including OV and shunt point, because this case was a single fistula with multiple feeders.

Conclusion:

sAVFs are a relatively rare disease with a complex vascular structure. For the adequate transarterial approach, TBO was useful for detecting the precise vasculature of sAVF.

Cirsoid aneurysm rupture of the splenic artery as a rare cause of fatal hemoperitoneum

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called "cirsoid" because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

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.