Intraosseous Arteriovenous Malformations Research Articles

Customised pre-operative cranioplasty to achieve maximal surgical resection of tumours with osseous involvement-a case series.

Surgical resection with bony margins would be the treatment of choice for tumours with osseous involvement such as meningiomas and metastasis. By developing and designing pre-operative customised 3D modelled implants, the patient can undergo resection of meningioma and repair of bone defect in the same operation. We present a generalisable method for designing pre-operative cranioplasty in patients to repair the bone defect after the resection of tumours. We included six patients who presented with a tumour that was associated with overlying bone involvement. They underwent placement of customised cranioplasty in the same setting. A customised implant using a pre-operative imaging was designed with a 2-cm margin to allow for any intra-operative requirements for extending the craniectomy. Six patients were evaluated in this case series. Four patients had meningiomas, 1 patient had metastatic breast cancer on final histology, and 1 patient was found to have an intra-osseous arteriovenous malformation. Craniectomy based on margins provided by a cutting guide was fashioned. After tumour removal and haemostasis, the cranioplasty was then placed. All patients recovered well post-operatively with satisfactory cosmetic results. No wound infection was reported in our series. Our series demonstrate the feasibility of utilising pre-designed cranioplasty for meningiomas and other tumours with osseous involvement. Following strict infection protocols, minimal intra-operative handling/modification of the implant, and close follow-up has resulted in good cosmetic outcomes with no implant-related infections.

A Life Threatening Bleeding Arteriovenous Malformation of the Maxilla Complicated with an Acute Cerebral Ischemic Stroke Recovered: Case Report and Review of Literature

Arteriovenous malformation (AVM) of the head and neck is a rare and potentially life-threatening entity due to massive hemorrhage, which poses a challenge to surgeons treating patients with these lesions. The head and neck region accounts for approximately 50% of all arteriovenous malformations (AVM), and the same region also accounts for about approximately 50% of intraosseous AVM in the maxillary facial region, which can be very dangerous, as a simple tooth extraction or a biopsy can lead to a major hemorrhage that may eventually cause death. The Treatment may be surgical or non-surgical. We present the case of a 27-year-old patient with an AVM of the maxilla complicated during his hospitalization for an acute cerebral ischemic stroke, from which he recovered.

Intraosseous arteriovenous malformation of the foot. Treatment by cementoplasty

Intraosseous arteriovenous malformation of the foot. Treatment by cementoplasty

Clinical and imaging features of intraosseous arteriovenous malformations in jaws: a 15-year experience of single centre

Intraosseous arteriovenous malformations in jaws (j-AVMs) are rare congenital high-flow vascular anomalies with a high tendency of life-threatening haemorrhage and are regarded as one of the most dangerous haemorrhagic diseases in maxillofacial region. Pre-treatment clinical and imaging evaluations serve as the most important diagnostic modalities. A retrospective study involved 211 patients with j-AVMs from November 2003 to November 2017 was performed. The male-to-female ratio of j-AVMs was approximately 4:3. The mean age of the patients with j-AVMs is 21.86. Bleeding was the main complaint associated with j-AVMs. J-AVMs occurred in the mandible more often than in the maxilla (64.93% and 32.23%, respectively). Most j-AVMs (95.26%) occurred in the posterior teeth region. Classical imaging features of j-AVMs included: an unclear maxillary sinus with a mild ground-glass appearance (maxillary j-AVMs) and a clear oval or irregular lucency that is mostly centred on the root of the first molar (mandibular j-AVMs) on OPGs, enhancement in the cancellous bone on contrast-enhanced CTs. Other atypical features of j-AVMs were also concluded. A comprehensive diagnose system based on clinical and imaging features of j-AVMs could provide valuable reference data for clinical management of j-AVMs and help avoid improper iatrogenic trauma or delayed treatment.

Intraosseous Arteriovenous Malformations in the Extremities Managed with Coils and Absolute Ethanol Treatment

The extremity intraosseous arteriovenous malformations (AVMs) are rare high flow vascular lesions for which the treatment remains challenging. The aim of the study wasto assess treatment methods, interim results, and complications of coils and absolute ethanol in managing extremity intraosseous AVMs via direct puncture approach. From 2009 to 2017, 12 patients (mean age, 27.5years; range, 3-54years) with extremity intraosseous AVMs underwent staged coils and absolute ethanol treatment via the direct puncture approach. All patients were symptomatic before the procedure as per the Schobinger staging system. The mechanical detachable coils and undetachable coils were used first followed by the injection of absolute ethanol used as a sclerosant agent via a direct puncture approach. Follow-up evaluation (6 to 72months; mean, 23.5months), including imaging and symptoms and signs, was performed in all patients. Twenty-seven absolute alcohol procedures were performed for patients with intravascular sclerosis (range: 1-3, mean: 2) with one procedure required per patient (n=2), 2 per patient (n=5), or 3 per patient (n=5). The average stretched length of the total coils per patient was 843.33cm. The amount of absolute ethanol used ranged from 10mL to 45mL (mean, 25.69mL) in a single session. Nine of twelve patients (75%) exhibited complete responses, and 3 patients (25%) exhibited partial responses. One patient experienced minor complication of transient motor nerve injury and completely recovered half a month later. No major complications occurred. The study provides strong evidence, suggesting that direct puncture and coils with absolute ethanol approach is an effective and safe treatment in patients with extremity intraosseous AVMs, yielding minor complications and good results.

Intraosseous arteriovenous shunt of lumbar spine mimicking a benign bone tumor: A case report and short review of the literature

BackgroundParaspinal arteriovenous shunts (PAVSs) remain a rare pathology, compared to the well-studied dural arteriovenous shunts. Intraosseous development of these lesions may mimick primary bone tumor. Case descriptionWe report of a 75 year-old lady with PAVS of lumbar spine mimicking an osseous tumor presenting without circulatory instability or neurologic deficits. Excision of the lesion was performed without complications. Her postoperative status was also bland. Histology revealed an intraosseous arteriovenous malformation (AVM). Its drainage had to be exclusively extra-spinal, inasmuch as no venous congestion of myelon or systematic circulatory disorder occurred. ConclusionsTreating physicians should include vascular malformations in differential diagnosis regarding bone tumors. A non-invasive angiographic method could be included in the preoperative work-up.

Intraosseus Arteriovenous Malformation of the Mandible: Extracorporeal Curettage and Immediate Replantation

Objective: To describe a surgical technique in the treatment of arteriovenous malformations of the mandible
 Methods:
 Design: Case Report
 Setting: Tertiary National University Hospital
 Participants: One
 Result: A 16-year-old boy underwent resection, extracorporeal curettage, and immediate replantation of the hemimandible for intraosseous arteriovenous malformation. Postoperative follow up and imaging at one- and six-months showed no signs of recurrence, new bone formation and consolidation of the replanted right mandible with good symmetry and function.
 Conclusion: Extracorporeal curettage followed by immediate replantation of the resected mandible seems to have yielded good early results in our case and may be a viable alternative especially when access to highly specialized microvascular surgical services is limited.
 Keywords: arteriovenous malformation; mandible, abnormalities; extracorporeal curettage

Diagnosis and conservative treatment of a rare case of femoral intraosseous arteriovenous malformation in a patient with polyostotic fibrous dysplasia: A case report.

Pure intraosseous arteriovenous malformation (AVM) in a limb bone is extremely rare. Furthermore, there is currently insufficient information on the diagnostic and therapeutic strategies for pure intraosseous AVMs. We herein report a case of pure intraosseous AVM of the proximal femur occurring in a patient with polyostotic fibrous dysplasia. The patient was a 39-year-old woman who presented with pain in the right thigh. Plain radiographs and computed tomography scans revealed a medullary lytic lesion with expansion and thinning of the bone cortex in the right proximal femur, mimicking a primary bone tumor. Magnetic resonance imaging (MRI) examination revealed intramedullary signal voids and feeding arteries arising from the deep femoral artery. A non-surgical approach using embolization and denosumab achieved satisfactory results, which included complete obliteration of the AVM, increased cortical thickness of the right proximal femur, and attenuation of the high-turnover bone metabolism 1 year later. Careful review of MRI images is crucial for distinguishing between bone tumors and intraosseous AVM, which exhibit signal voids and feeding arteries, in order to avoid unnecessary interventions such as bone biopsy or surgery.

Combined soft tissue and intraosseous arteriovenous malformations of hand and foot

Combined soft tissue and intraosseous arteriovenous malformations of hand and foot

Endovascular treatment of an intraosseous arteriovenous malformation of the mandible in a child. A case Report

The modern application of interventional radiology techniques is revolutionizing the treatment of the vascular malformations of the head and neck. In fact, the morbidity related with the surgical extirpation of the malformation might be drastically reduced with the use of an endovascular approach. The present report describes the case of a 11 years old male affected by a large intraosseous arteriovenous malformation of the mandible. The coil embolization of the main drainage vein caused the spontaneous regression of the lesion and avoided a mutilating surgery and severe psychological sequels. A multidisciplinary approach of these case is mandatory. A careful clinical and radiological study of the patient is essential for a proper management. The choice of the treatment should be based on the location and extension of the malformation, age of the patient, experience with endovascular techniques and clinic. Key words:Endovacualr approach, intraosseous arteriovenous malformation, head and neck, child.

The rare case of a large complex intraosseous cranial arteriovenous malformation with successful multidisciplinary management

Intraosseous cranial arteriovenous malformations (AVMs) are very rare, challenging entities. The authors report the case of an extracranial parietooccipital vascular lesion. A 12-year-old boy presented with accelerated growth of a right scalp lesion over a few months. Digital subtraction angiography showed a large, right parietooccipital intraosseous AVM with multiple complex arterial feeders. Treatment of these lesions is difficult and can necessitate a multidisciplinary approach. In the featured case, 6 embolization procedures were performed over 1 year, including both transarterial and transvenous approaches, followed by total resection. The authors describe what is thought to be the second case of an AVM originating in the cranial bones and the first case with successful multidisciplinary management.

Special Consideration for Intraosseous Arteriovenous Malformations.

Intraosseous arteriovenous malformations (AVMs) have been associated with distortion, hypertrophy, osteolytic skeletal changes, bleeding, leg length discrepancy, and pathologic fracture. Computed tomography or magnetic resonance imaging is helpful in the evaluation of the extent and depth of intraosseous AVMs and associated soft-tissue AVMs. Treatment approaches can differ, depending on the angiographic classification. Embolotherapy with ethanol, coils, or n-butyl cyanoacrylate is the primary treatment for symptomatic intraosseous AVMs, and the goal of treatment is symptom improvement with few complications.

Immunohistochemical and histochemical characterization of intraosseous arteriovenous malformations of the jaws: analysis of 16 cases with emphasis on GLUT-1 immunophenotype

Intraosseous vascular lesions of the craniofacial region are rare and may cause diagnostic and therapeutic challenges. The purpose of this study was to characterize 16 cases of intraosseous arteriovenous malformations (AVMs) affecting the jaws. Immunohistochemical evaluation was performed using antibodies against α-smooth muscle actin (α-SMA), desmin, CD31, D2-40, and glucose transporter 1 (GLUT-1). Staining with elastic Verhoeff-Van Gieson and Masson trichrome histochemical stains was also performed. No gender predilection (female:male ratio=1:1) was observed, with patients' mean age being 50.8years (SD of ±13.9; range 28-71years). Predilection for the mandible was observed (12 of 16 [75%]). Immunohistochemically, diffuse endothelial CD31 staining was noted, and α-SMA strongly highlighted smooth muscle cells and pericytes. Desmin-positive vessels were identified in 9 of 16 AVMs (56.3%). D2-40 was uniformly negative in all specimens. AVMs were negative for GLUT-1 (11 of 14 [78.6%]) except for 2 cases (2 of 14 [14.3%]) exhibiting focal limited cytoplasmic GLUT-1 immunoreactivity. One case was equivocal for GLUT-1. Masson trichrome highlighted smooth muscle cells, and elastic fibers were identified in thick-walled arteries. AVMs of the jaws generally lack expression of GLUT-1, similar to soft tissue vascular malformations. Clinicoradiographic features of intraosseous AVMs in the present study were consistent with the findings of previous studies, although mean age was higher.

E-027 high volume dual lumen balloon catheter onyx embolization of a large mandibular venous lake associated with a hemorrhagic intraosseous mandibular arteriovenous malformation

Introduction Mandibular venous lakes associated with intraosseous mandibular arteriovenous malformations (AVM) can lead to catastrophic, life-threatening hemorrhage. Dual lumen balloon catheter Onyx embolization may play a significant role in prevention of hemorrhage, lesion obliteration and supporting a multidisciplinary treatment plan for these rare and difficult lesions, whose large size may necessitate unusually high volume Onyx injection. This report demonstrates the feasibility of this approach. Methods Case report and review of the literature. Case report A 16-year-male with a history of a “birthmark” on his right lower face and jaw presented with right mandibular molar tooth loosening, facial swelling and two spontaneous episodes of bleeding from the mouth soaking his pillow at night. Dental panoramic examination demonstrated an expansile lucent lesion in the right mandible. Biopsy was aborted after a small needle aspirate was composed of 100% blood. A lingual tilt of the affected teeth, gum redness and a palpable thrill over the right lower jaw were noted. CT angiography revealed a large intraosseous mandibular AVM. Catheter angiography demonstrated both superficial and intraosseous mandibular components. A large right mandibular venous varix or “venous lake” predominated the intraosseous component and measured up to 5.8 cm in size, surrounding the roots of several mandibular molars. Embolization was performed to reduce bleeding risk and support multidisciplinary treatment after discussion with oral surgery. Two facial artery branches supplying extraosseous components were embolized with PVA particles (355–500 um) to reduce flow into the malformation and aid Onyx penetration. A 4 mm × 10 mm Scepter C balloon allowed injection of approximately 34.5 cc of a combination of Onyx 34 and Onyx 18 into a branch supplying the intraosseous varix over 103 min with total output air kerma of 1458 mGy, resulting in complete obliteration of the venous lake. Residual superficial extraosseous AVM component fed by distal facial and lingual arteries drained to superficial veins. Transient right facial tenderness and swelling was experienced as well as mild numbness of the right lower lip and tongue. He returned to school two days after embolization. No further bleeding occurred. Multidisciplinary treatment with further embolization followed by mandibular surgical reconstruction is planned. Discussion Embolization comprises an important adjunctive or primary treatment modality for intraosseous mandibular AVM. While multiple embolic agents have been used in transarterial, transvenous or percutaneous approaches, the slow, controlled delivery of Onyx confers particular advantage in the setting of rapid shunting into large mandibular venous lakes. From the transarterial approach, dual lumen balloon catheter flow control enables high volume injection of Onyx across fistulous connections to occlude even large lesions, theoretically dramatically reducing bleeding risk. The volume of Onyx injected into the mandibular venous lake in our case of approximately 34cc, while exceeding generally recommended maximum injection guidelines of 1cc DMSO/10lbs pt. weight, was tolerated without significant adverse effect, allowing lesion obliteration as the first stage of a multidisciplinary treatment plan. High volume Onyx embolization of intraosseous mandibular AVMs using dual lumen balloon catheters is well tolerated and represents an important treatment option for these difficult lesions. Disclosures M. Fiesta: None. B. Atchie: None. N. Mehta: None. J. Barr: 2; C; Microvention. 4; C; Medtronic. R. Novakovic: None. B. Welch: 5; C; Covidien, clinical proctor. J. White: None. K. Rickert: None. M. Zide: None. P. Tiwana: None. G. Pride: 2; C; Sequent Medical.

Gingival bleeding of a high-flow mandibular arteriovenous malformation in a child with 8-year follow-up.

Intraosseous arteriovenous malformations (AVMs) in the head and neck region are uncommon. There are several types and they can have a wide range of clinical presentations. Depending on the blood flow through the AVM, the treatment may be challenging for the attending team and may lead to life-threatening hemorrhages. A clinical case report is presented. A 9-year-old girl, seen for gingival bleeding during oral hygiene, was found to have a high-flow AVM located within and around the mandible. Two-stage treatment consisted of intra-arterial embolization followed by intraoral injection of a sclerosing agent 8 weeks later. At the 8-year follow-up, imaging study showed no evidence of recurrent lesion inside or outside the bone. The final outcome is a correct occlusion with a symmetric facial result. This case shows that conservative treatment may be the first treatment option mostly in children. Arteriography and transcortical injection were enough to control the AVM.

Surgical Treatment of Vascular Malformations of the Facial Bones

To characterize intraosseous vascular malformations and describe the most appropriate approach for treatment according to clinical experience and a review of the published data. We performed a retrospective review of 11 vascular malformations (7 venous and 4 arteriovenous) of the facial bones treated during a 10-year period using en bloc resection or intraoral aggressive curettage alone or preceded by endovascular embolization. Corrective surgery was planned to address any residual bone deformities. The cases were reviewed at a mean follow-up point of 6 years. Facial symmetry was restored in the cases requiring reconstruction. Tooth sparing was possible in the case of jaw and/or maxillary localization. Recanalization occurred in 14% of the venous and 33% of the arteriovenous malformations. Facial intraosseous venous malformations can be successfully treated using surgery alone. Facial intraosseous arteriovenous malformations will be better addressed using combined approaches. Aggressive curettage will obviate the need for extensive surgical resection in selected cases.

Two-year follow-up of osseointegration and rehabilitation in a patient with oral and maxillofacial arteriovenous malformations

The case of a patient with high-flow arteriovenous malformations (AVMs) affecting the mandible and lower face is presented. The patient had undergone surgical resection, sclerotherapy, and transcatheter embolization over the course of 16 years. As a result, all teeth except for the lower left third molar were missing, and a mass of arteriovenous malformed soft tissue covered the residual alveolar ridge. Implant placement surgery was performed in his mandible after treatment of the AVMs. Osseointegration of the implants placed in the mandible affected by the AVMs was evaluated. Rehabilitation in the absence of the alveolar ridge or keratinized gingiva was also evaluated. The implant stability quotient (ISQ) was measured before fabricating the restoration. An implant-supported partial denture was placed 4 months postoperatively. No implant failure was found; no bleeding on probing was present. The occlusion and masticatory function were satisfactory at 2-year follow-up. Osseointegration was safely achieved in the bone affected by the intraosseous AVMs that had been embolized. The success of an implant support prosthesis depends not only on the condition of the bony tissue but also on the surrounding soft tissue.

Intraosseous Arteriovenous Malformation of the Sphenoid Bone Presenting with Orbital Symptoms Mimicking Cavernous Sinus Dural Arteriovenous Fistula: A Case Report

Intraosseous arteriovenous malformation (AVM) in the craniofacial region is rare. When it occurs, it is predominantly located in the mandible and maxilla. We encountered a 43-year-old woman with Klippel-Trenaunay syndrome affecting the right lower extremity who presented with a left orbital chemosis and proptosis mimicking the cavernous sinus dural arteriovenous fistula. Computed tomography angiography revealed an intraosseous AVM of the sphenoid bone. The patient's symptoms were completely relieved after embolization with Onyx. We report an extremely rare case of intraosseous AVM involving the sphenoid bone, associated with Klippel-Trenaunay syndrome.

Extensive bilateral arteriovenous malformations of the mandible successfully controlled by combined endovascular and transcutaneous angio-embolization: Case report and review of the literature

We report a unique case of extensive bilateral arteriovenous malformation (AVMs) in a child's mandible, discuss treatment options and review literature. A healthy 8 year-old girl presented with bright blood of unknown source found on her pillow. Three large AVMs involving the symphyseal region and bilateral mandibular bodies were found on angiography. Due to the extent of surgical resection required, the patient underwent a series of endovascular and transcutaneous angio-embolization. In cases of extensive intraosseous AVMs, serial embolization procedures can be successful in controlling episodes of hemorrhage and allow for bone remineralization. A multidisciplinary approach by otolaryngologists and neurointerventional radiologists can optimize the results.

A rare case of intracerebral hemorrhage due to arteriovenous malformation located at petrous portion of the temporal bone.

Primary intraosseous arteriovenous malformations (AVM) are not infrequently encountered. We report a case of intraosseous arteriovenous malformation arising in the left temporal bone. A 51-year-old male patient presented with loss of conscious. Computerized tomography displayed hematoma measuring 4 cm in diameter in the left temporal lobe. Digital subtraction angiography (DSA) showed that a temporal bone AVM supplied by all the branches of the external carotid artery and vertebral artery. Many treatment modalities can be considered for preoperative steps and/or for definitive treatment. We preferred embolisation for this vascular pathology. To the best of our knowledge this represents the first case of an intraosseous arteriovenous malformation located in the temporal bone.