Craniofacial Vascular Malformations Research Articles

Unanticipated Difficulty in an Anticipated Difficult Airway in the Neurointervention Suite: A Case Report

AbstractAirway management of patients with craniofacial vascular malformations poses many challenges. Establishment of a secure airway is a prerequisite for safe anesthetic management of these patients. We report a case of a 45-year-old man presenting with a facial vascular malformation involving the tongue, parapharynx, and extending into the neck, resulting in airway compromise scheduled for endovascular embolization.

Interventional management of high-flow craniofacial vascular malformations: a database analysis and review of the literature

BackgroundHigh-flow craniofacial vascular malformations are uncommon, locally aggressive lesions that pose a therapeutic challenge.ObjectiveTo report our experience with the treatment of high-flow craniofacial vascular malformations.MethodsAfter institutional review board approval was...

4:03 PMAbstract No. 333 - Histopathologic evidence of recanalization of Onyx in craniofacial vascular malformations

4:03 PMAbstract No. 333 - Histopathologic evidence of recanalization of Onyx in craniofacial vascular malformations

Vascular neurocutaneous disorders: neurospinal and craniofacial imaging findings.

We review the neurospinal and craniofacial imaging findings in vascular neurocutaneous disorders. The patients presented with cutaneous and cerebral lesions associated with craniofacial abnormalities or spinal lesions. Vascular neurocutaneous disorders may involve segmental or localized lesions associated with either low- or high-flow vascular malformations. Other neuroimaging findings include vascular occlusive changes with ischemic stroke, ectatic arteries, aneurysm, cortical migrational disorders such as hemimegalencephaly and congenital anomalies of the posterior fossa. Craniofacial vascular malformations, eye abnormalities, facial deformity and spinal lesions have been reported in some cases. Hamartomatous formation and malignancy have also been reported in some cases. Correlation of clinical findings with neurospinal and craniofacial abnormalities is important to reach a specific diagnosis of some vascular neurocutaneous disorders.

P-025 Interventional Treatment of High Flow Craniofacial Vascular Malformations

ObjectiveHigh flow craniofacial vascular malformations are uncommon lesions that pose a very difficult therapeutic challenge. They are locally aggressive lesions that can present in several different ways from completely asymptomatic...

Endovascular Management of Head and Neck Vascular Malformations

Vascular malformations are congenital lesions caused by errors in endothelial development. Mulliken’s classification of vascular malformations subdivides lesions into high-flow (such as arteriovenous malformations) and low-flow lesions (such as venous and lymphatic malformations). Although they can occur virtually anywhere in the body, the majority occur in the head and neck. The therapeutic management of vascular malformations is challenging even for highly experienced practitioners; they are often complex lesions that require a specialized multidisciplinary team approach for optimal treatment. Currently, endovascular therapeutic techniques, such as sclerotherapy, with or without adjunctive surgical resection, are among the first-line treatment options for vascular malformations. There are a wide variety of embolosclerotherapy agents which have been used effectively to treat vascular malformations. This article presents a brief overview of the endovascular management of craniofacial vascular malformations.

Management of Benign Head and Neck Tumors

: Endovascular procedures for benign head and neck tumors include embolization, stenting, and balloon test occlusion. A transarterial (or endovascular) approach forms the mainstay of treatment for head and neck bleeding as well as for transarterial chemotherapy for head and neck neoplasms. A combination of percutaneous and transarterial approaches may be needed in the embolization of high-flow craniofacial vascular malformations (VMs) and hypervascular tumors. This is a review of the current clinical applications of a variety of percutaneous and endovascular interventional procedures of the extracranial head and neck. The tumors that require embolization in the head and neck most commonly include glomus tumors, angiofibromas, and meningiomas. Many other types of tumors that may also require preoperative embolization include the following: hypervascular metastases, esthesioneuroblastomas, schwannomas, rhabdomyosarcomas, plasmacytomas, chordomas, and hemangiopericytomas. The goal of tumor embolization is to selectively occlude the external carotid artery (ECA) feeders through intratumoral deposition of embolic material. The embolic agents in common use are polyvinyl alcohol (PVA), Embospheres (BioSphere Medical, Rockland, Mass), liquid embolic agents (glue, ethylvinyl alcohol copolymer [EVOH], or Onyx [ev3, Irvine, Calif]), gelatin sponge (Gelfoam; Phadia, Uppsala, Sweden), and coils. The embolization is ideally performed 24-72 hours before surgical resection to allow maximal thrombosis of the occluded vessels and prevent recanalization of the occluded arteries or formation of collateral arterial channels. Preoperative embolization is cost-effective and tends to shorten operation time by reducing blood loss and the period of recovery.

Management of Severe Craniofacial Vascular Malformation Operated Under Bypass

Cardiopulmonary bypass (CBP) and circulatory arrest as an assist in the surgical excision of a severe facial vascular malformation were first described by Mulliken et al in 1979. Later on, its use had expanded for resection of intracranial vascular malformations. However, to date, there have not been any published series of these procedures being used in the resection of craniofacial vascular malformations. We sought to review the first 10 surgical procedures performed at McGill University Health Centre for large vascular malformations resection using hypothermic CBP with or without circulatory arrest. All consecutive patients at the McGill University Health Centre who had a craniofacial vascular malformation resected with the aid of CBP were reviewed. A comparison of the classic midline sternotomy with cardiac arrest to percutaneous femoral bypass with hypothermic "low flow" was performed. Charts were reviewed for the operative intervention including bypass parameters and short- and long-term complications of the procedure. Cardiopulmonary bypass was used in 9 patients for 10 surgical procedures for the resection of a variety of craniofacial vascular malformations from 1987 to 2001. All lesions had sclerotherapy and embolization of the feeding vessels 72 to 96 hours preoperatively. The average age of our patients was 21 ± 13.4 years (2-37 years). Procedures were conducted via either an open bypass or a closed femoral approach. There were no mortalities. There were 2 major cardiac intraoperative complications and 1 major postoperative complication, which were managed with no sequelae. The average length of postoperative hospital stay was 10 days. All patients went on to full recovery. The blood transfusions varied from 10 U to 0 U for our last patient. The assistance and adjunct of CBP are a useful procedure in the resection of very large vascular malformations, in selected cases. There were no major long-term complications in this series. With the evolution of our approach, the use of complete circulatory arrest was not required in the majority of cases, and an adequate resection was usually possible with the low-flow state alone as we developed this technique with more experience through the process.

Embolization of High-Flow Craniofacial Vascular Malformations with Onyx

Various techniques and materials have been used for the endovascular treatment of craniofacial high-flow arteriovenous vascular malformations, because their rarity precludes standardization of their treatment. The aim of this retrospective review is to assess Onyx as the primary embolic agent in the treatment of these vascular malformations. Six patients with arteriovenous fistulas and 3 with arteriovenous malformations (AVMs) of the head and neck region were treated with intra-arterial (IA)/direct percutaneous injections of Onyx. Adjunctive maneuvers used during embolization included external compression of the arterial feeders or venous outflow (6 patients), balloon assist (4 patients), and direct embolization of the draining vein remote to the fistula site (1 patient). n-butyl-2-cyanoacrylate (n-BCA) was used in addition to Onyx for rapid induction of thrombosis in a large venous pouch (1 patient) and for cost containment purposes (1 patient). Four patients were treated surgically after the embolization. There were no neurologic complications secondary to the embolization procedure. The arteriovenous shunt was eliminated in all of the fistulous lesions and 2 of the 3 AVMs. The embolization was incomplete in 1 patient with a large AVM who declined further endovascular or surgical procedures. Untoward events included 2 instances of catheter entrapment (of 9 IA injections), blackish skin discoloration necessitating surgical revision in 1 patient, and difficulty of balloon deflation/wire withdrawal during a balloon-assisted embolization. Onyx appears to be a safe and effective liquid embolic agent for use in the treatment of craniofacial high-flow vascular malformations with distinct advantages and disadvantages compared with n-BCA.

Commentary on “Interdisciplinary management of craniofacial vascular malformations” by Kubiena, et al

Commentary on “Interdisciplinary management of craniofacial vascular malformations” by Kubiena, et al

Interdisciplinary management of craniofacial vascular malformations

Beside their sometimes unsightly appearance, vascular malformations of the head and neck area can lead to very severe functional problems. Reduced field of vision and impairments in breathing and swallowing can occur and are serious problems to deal with. During the last 4 years, 17 patients with vascular malformations of the head and neck region were treated in our department. Initially, the patients were evaluated by an interdisciplinary team consisting of specialists in pediatrics, radiology, dermatology, and plastic surgery. A diagnostic algorithm of radiological investigation is established; this consists of gadolinium-enhanced magnetic resonance imaging, magnetic resonance angiography, and multi-slice computer tomography to provide as a basis for individual treatment. In four patients with well identifiable feeding vessels, a two-stage concept consisting of embolization and immediate resection was performed. A detailed explanation of the diagnostic and therapeutic steps with regard to the specific imaging necessities and treatment modalities is outlined. The aim is to emphasize the necessity for a multidisciplinary approach in dealing with large craniofacial vascular malformations. Minimal blood loss, moderate operating time, and overall satisfactory postoperative results, both functional and cosmetic, are the aims of this interdisciplinary management.

Craniofacial Vascular Malformations in Wyburn-Mason Syndrome

Wyburn-Mason syndrome (WMS) is a rare syndrome associated with multiple arteriovenous malformations (AVMs) involving the orbit, brain and/or face. The purpose of this study was to analyze the imaging spectrums of craniofacial vascular malformations in 14 patients with WMS. The medical records of 14 patients with the diagnosis of WMS who underwent neuroimaging studies (computed tomography [CT], 8; magnetic resonance imaging [MRI], 12; conventional angiography, 14) were reviewed, emphasizing the location, extension and type of facial, orbital and brain vascular malformations. Complete WMS was defined as vascular malformations involving all the 3 zones of the face, orbit and brain, while partial WMS was considered as vascular malformation distributed in 2 zones. The craniofacial vascular malformations were confined on the left side in 7 patients, 2 were found on the right side, while the remaining other 5 patients had midline brain AVMs involving both sides. All but 1 of these 14 patients had orbital and/or brain AVMs; facial vascular malformations were documented in 5 patients. The most common site of involvement was the optic nerve (n = 12), followed by the retina (n = 10), optic chiasma/hypothalamus (n = 9), thalamus (n = 7), basal ganglion (n = 5), midbrain (n = 2), occipital lobe (n = 1), temporo-occipital lobe (n = 1) and fronto-temporo-parieto-occipital lobe (n = 1). The complete form of WMS was found in 2 patients and the partial form in 12. CT, MRI and conventional angiography have the capacity to demonstrate the extent of intracranial AVMs. However, MRI is superior to both CT and angiography for detecting the size, extent of AVMs and the effects of AVMs on adjacent brain. Conventional angiography is superior to both CT and MRI in determining the detailed angioarchitecture of AVMs. WMS has a wide spectrum of multiple AVMs involving unilateral or bilateral craniofacial regions. The most common involved site is the orbit, followed by the brain. WMS should be considered in patients with ocular AVMs associated with brain AVMs.

Book reviews

This is the second of four volumes written by two of the leading experts in modern interventional neuroradiology. It is an authoritative account of the treatment, by embolizing techniques, of the various types of craniofacial vascular malformations and tumours of the head and neck, including meningiomas, neurinomas, juvenile angiofibromas, branchial paraganglionomas, thyroid and parathyroid adenomas and various malignant tumours.