Percutaneous sclerotherapy for facial venous malformations: subjective clinical and objective MR imaging follow-up results

BACKGROUND AND PURPOSE

Venous malformations are the most common of all vascular anomalies, 40% of which are found in the head and neck. We discuss results of percutaneous sclerotherapy using bleomycin for facial VMs by using subjective clinical assessment and objective changes on MR imaging.

MATERIALS AND METHODS

Thirty-seven patients with facial VMs were treated by percutaneous sclerotherapy with bleomycin. Of these, 31 patients with 32 lesions had pre- and posttreatment MR imaging. Each lesion received between 1 and 9 sclerotherapy sessions (average, 3.5). MR findings and clinical results of treatment were retrospectively reviewed. Clinical results were based on the physician's physical examination and interview of the patient; these were classified as worse, unchanged, or better. Objective results on MR imaging were classified as worse, no change, minor improvement (<50% decrease in size), marked improvement (>or=50% decrease), or cure. Objective and subjective results were compared.

RESULTS

Twenty-one lesions showed objective improvement on MR imaging. Of these, 10 showed minor decrease in size and 11 showed marked decrease. Eleven lesions showed no change on MR imaging. No VMs were worse or completely cured. Subjectively, 29 patients and 30 clinicians thought that lesions improved. Four of 32 (12.5%) patients suffered minor transient complications.

CONCLUSIONS

Percutaneous sclerotherapy by using bleomycin is a safe technique to objectively decrease size and subjectively alleviate symptoms of facial VMs. Subjective clinical improvement is not always associated with visual size reduction on MR imaging. Minimal size reduction or partial fibrosis of the lesion may be enough to achieve subjective clinical improvement.

Surgical disconnection of cortical venous reflux as a treatment for Borden type II dural arteriovenous fistulae

OBJECTIVE

The presence of cortical venous reflux is recognized as an indicator of increased risk of intracranial hemorrhage and neurological deficits in cranial dural arteriovenous fistulas. Its disconnection is well accepted as a treatment for fistulas with direct cortical reflux (Borden type III), but the role of disconnection of the cortical venous reflux in the management of fistulas that involve the venous sinus and cortical venous reflux (Borden type II) is still a matter of debate. We analyze the experience of the Toronto Brain Vascular Malformation Study Group in the management of these lesions by simple cortical venous reflux disconnection and its impact in the future risk of bleeding.

METHODS

From June 1984 to August 2004, 347 patients with dural arteriovenous fistulas, either cranial or spinal, were evaluated by the group. Fifty-three patients had a Borden type II dural arteriovenous fistulas. Twenty-five patients were submitted to simple surgical disconnection of the dural arteriovenous fistulas, two were lost for follow-up. There were 15 females and 8 males, with mean age at diagnosis of 53.9 years. Follow-up time was 112.6 patient-years, from 2 months to 11 years, mean 4.9 years. Endovascular treatment was attempted in all patients, but no disconnection was possible. Twelve patients had their fistulas completely occluded by endovascular means, but are not analyzed here. There were four complications from the 93 endovascular procedures, and 3 from the 27 surgical procedures. Two patients required a repeated surgical procedure. No episode of intracranial hemorrhage or worsening neurological deficit was seen after disconnection of the cortical venous reflux in 4.9 years of follow-up.

CONCLUSION

Simple surgical disconnection of the cortical venous reflux maybe an option in the management of patients with Borden type II dural arteriovenous fistulas. This procedure is a much smaller surgical undertaking and is associated with fewer complications than attempts to resect or pack the whole fistula, especially if located in the skull base.

Anterior ethmoidal artery aneurysm and intracerebral hemorrhage

The association between the formation of intracranial aneurysms and situations of increased blood flow in certain areas of the brain is well accepted today. It has been seen in association with arteriovenous malformations of the brain, carotid occlusion, and Moyamoya disease. The occurrence of aneurysms in small arteries of the skull base, with the exception of the intracavernous carotid artery, however, is rare. We report a case of a 55-year-old woman who presented with an intracerebral hemorrhage caused by a ruptured anterior ethmoidal artery aneurysm. To the best of our knowledge, this is only the second case of documented intracranial bleeding from such a lesion.

Shotgun pellet embolization to the posterior cerebral circulation

The embolization of missiles to the intracranial circulation is a rare event. We describe here a case of a man shot by a shotgun, presenting with a posterior fossa stroke and occlusion of the superior cerebellar artery by a metallic pellet. To our knowledge, this is the third case of posterior fossa circulation pellet emboli.