Scalp Arteriovenous Malformations Research Articles

Scalp arteriovenous malformations - 20 years of experience in a tertiary healthcare centre.

Scalp arteriovenous malformations (SAVM) are extremely uncommon vascular malformations, with only ~200 cases published in the English language in the past years. The objective of the present study was to describe the experience of a single reference service in neurosurgery. This is a descriptive and retrospective study conducted at our institution, which included cases of SAVM treated between 2001 and 2022. All information were extracted from the medical records of our institution. Patient confidentiality was preserved. Furthermore, an illustrative case has been described in detail. Seven patients were included. The male-to-female ratio was 2.5: 1 and the mean age was 23.3 (3-42) years. Most cases (56.4%) were spontaneous and the lesions were located in the frontal (28.7%) and parietal (28.7%) regions. All lesions were supplied by more than one feeder, with the superficial temporal and occipital arteries being the most commonly involved (71.5%). Six patients underwent preoperative embolization, and 56.4% patients had scalp necrosis. Five patients underwent surgical resection, all without recurrence and with good postoperative evolution. More than one artery was involved in all cases, and the properties of the involved vessel influences the approach strategy. Surgical treatment is curative, and preoperative embolization helps reduce bleeding during the surgery. Complete resection of the lesions prevents associated complications, such as bleeding or recurrence. Scalp necrosis is a frequent complication in the treatment of these lesions, and a multidisciplinary approach involving reconstructive plastic surgery should always be considered.

Management of scalp arteriovenous malformations: a rising trend towards percutaneous direct puncture embolization technique-our experience.

Scalp arteriovenous malformations (AVMs), or cirsoid aneurysms of the scalp, usually present with troublesome symptoms and cosmetic disfigurement. Endovascular/percutaneous embolization has evolved as a sole treatment method or adjunct to surgical excision in the management of scalp AVMs with an excellent outcome. To discuss minimally invasive techniques for treating scalp AVMs as well as to highlight the role of embolization before surgery. This is a retrospective study of 50 patients with scalp AVM who underwent embolization (percutaneous/endovascular) during 2010-2019 at a tertiary care center. n-butyl cyanoacrylate (n-BCA) was used as an embolizing agent in all the cases and the patients were followed up at three- and six-month intervals with Doppler evaluation. A total of 50 patients were included in the study. The occipital region was the most common location; 82% were Schobinger class II lesions and 18% were class III lesions. Thirteen patients had small-sized AVMs and 37 patients had large-sized AVMs. Post-embolization surgery was performed in 36 patients. Of the patients, 28 underwent percutaneous embolization, 20 underwent endovascular embolization, and two underwent both to achieve complete embolization of the lesion. The number of percutaneous procedures increased in the latter half of the study period as the safety and efficacy of the technique were established. No major complications were seen in this study. Embolization of scalp AVMs is a safe and effective technique and can be used in isolation for small lesions and as an adjunct procedure to surgery for large-sized lesions.

Surgical Excision of Multi-layered Scalp AVM: Case Report and Literature Review

Scalp arterio-venous malformations (AVM) are rare conditions that are congenital, traumatic, or post infectious in nature. These lesions may be found incidentally or owing to signs and symptoms that they produce, and they most often need surgical treatment. Here, we have reported our experience of the surgical management of multi-layered scalp AVM without interosseous intracranial connections with a short review of the literature. In this case report, we described the diagnosis, both the clinical and radiological features of a patient having a multi-layered scalp arteriovenous malformation existing in the galea and pericranial layers separately who underwent surgical excision of these lesions at Ibn Al Haitham Hospital without preoperative embolization and a follow-up period of 15 months. The lesions were successfully excised surgically; scalp cosmetic aspects were acceptable. There was no major postoperative complication or recurrence until last follow-up. We conclude that with appropriate preoperative surgical planning, scalp AVM can be excised without major complications leading to excellent outcome. However, preoperative embolization is increasingly used to reduce vascularity and hemorrhage during surgery.

A Case of Scalp Arteriovenous Malformation Treated by Transvenous Embolization Using Onyx.

We treated a case of scalp arteriovenous malformation (sAVM) by transvenous embolization using Onyx. We describe the case of a 17-year-old woman with a pulsatile mass at the right temporal area. DSA identified sAVM with the venous pouch between the right occipital artery (OA) and the right two occipital veins (OVs), which was also fed by multiple branches of the right posterior auricular artery (PAA) and superficial temporal artery (STA). The shunts were completely occluded by the reverse pressure cooker technique (RPCT), which involves navigating the balloon catheters just distal to the shunt point in the OVs approaching from the right external jugular vein (EJV) and injecting Onyx to each feeder retrogradely with balloons inflated. This technique may be useful for treating sAVM with venous angioarchitecture enabling a transvenous approach.

Successful en bloc resection with acceptable cosmesis of a right recurrent giant scalp-orbital AVM causing severe disfigurement: a case report

Scalp arteriovenous malformation (AVM) accounts for only 8.1% of all AVM cases. These lesions are made up of an abnormal fistulous tangle of tortuous dysmorphic network of vessels “vascular nidus” directly connecting between the feeding arteries and draining veins, without capillary connection, located within the incision subcutaneous layer.
 With time, these congenital lesions may evolve and enlarge and clinically manifest with variable features. The only effective method of preventing evolution of these malformations is to exclude the lesion completely from the circulation. Involvement of the orbit and face may cause severe facial disfigurement, proptosis, visual obstruction and even facial palsy. These lesions may be complicated by ulceration, infection and profuse bleeding.
 We present a rare case of 40-year-old female with a recurrent congenital scalp-orbital AVM causing proptosis, visual obstruction on the right eye with severe facial disfigurement. The lesion was successfully excised with acceptable cosmesis and removal of the visual obstruction. A brief literature review, imaging findings and the surgical techniques have been presented.

Combined Treatment of High-Flow Scalp Arteriovenous Malformations.

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. 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. 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%). 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.

Management of Ruptured Scalp Arteriovenous Malformation: A Rare Case and Literature Review

Arteriovenous malformation (AVM) are vascular anomalies that arise due to abnormal connection with shunting of blood from arteries to veins without an intervening capillary network. They are mostly found intracranially but extracranially, the scalp AVM cases are also well reported. However, arteriovenous malformation (AVM) of the scalp is a rare lesion whose natural history is not clearly understood. The clinical manifestation of AVM includes asymptomatic state, local discomfort, headaches and occasional scalp necrosis leading to massive haemorrhage. CT or MR angiography remains the cornerstone for investigation. The options of treatment include complete surgical excision, embolization or a combination of the two modalities. We present the successful management of a young man who presented with a torrential bleeding from a ruptured scalp arteriovenous malformation and had to undergo emergency complete excision followed with a rotational flap for the scalp reconstruction.

Excision of Large Scalp Arteriovenous Malformations with Aesthetic Scalp Reconstruction.

BACKGROUNDScalp arteriovenous malformations (SAVMs) are seen in young individuals and skin involvement is common in large SAVMs. They are commonly seen in younger age group too. Pre-operative embolization followed by surgical excision and hair bearing scalp reconstruction with tissue expansion are the treatment of choice. Therefore, proper selection of tissue expander for reconstruction of hair bearing scalp, seems essential. This study evaluated excision of large SAVMs with aesthetic scalp reconstruction.METHODSWe described management of 10 patients of large SAVMs with cutaneous involvement. All patients underwent pre-op embolization followed by surgical excision and hair bearing scalp reconstruction with tissue expansion. RESULTSAll cases of large SAVMs healed well with minor complications.CONCLUSIONWhile complete surgical excision with extirpation of the nidus is considered as the gold standard treatment, aesthetic hair bearing scalp restoration is also of paramount importance for the patient. This is done by using scalp tissue expansion after proper selection of the expander.

Scalp Arteriovenous Malformation: Double Row Purse String Suture (DROPS) Technique to Decrease Intra-operative Bleeding

Scalp arteriovenous malformations (AVMs) are high flow lesions with complex vascular anatomy. Excessive bleeding is a frequent surgical complication in resection of these lesions, for which many techniques have been suggested. Percutaneous suturing of the feeding vessels along with careful blood pressure control is reported as a method to reduce intra-operative bleeding. Skin shortage is a problem during skin repair and skin graft is often needed, but this problem has not been encountered with the present technique. Scalp AVMs without intracranial involvement are candidates for this technique. Patients are prepared for open surgical resection of the scalp AVM. After routine preparation, a double row of continuous interlocking purse string sutures are placed around the lesion periphery, deep to the galea, to temporarily interrupt the feeding arteries (Fig. 1). Then, the overlying skin is incised and skin flaps created by shaving the nidus from skin and then from the deep fascia in a bloodless field (Fig. 2). Next, the feeding arteries and draining veins are ligated. The skin is closed primarily, covered by a tie over compression wound dressing. Finally, the purse string sutures are removed. There was no need for blood transfusion and no significant change in haemoglobin after the procedure in any of our cases.Figure 2Creation of skin flaps and excised lesion in a bloodless field.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Five patients were operated on using the technique. On long term follow up (mean ± standard deviation 5.5 ± 1.5 years) the cosmetic result was promising, without recurrence. Surgical resection can be performed with confidence in a bloodless field without needing a skin graft. This technique has been used in other body parts, but owing to the bony skull, it is more efficient for scalp AVMs.

Diagnosis and Treatment of Scalp Arteriovenous Malformations With Intracranial Extension

Scalp arteriovenous malformations (AVMs) are rare entities that may present as large, tortuous vascular lesions with resultant craniofacial deformity. Radiologic findings include feeding arteries and veins associated with dilated tortuous vessels. Intracranial extension is rare. A 5-year-old African American male presented with an occipital mass presumed to be a dermoid cyst on referral. Further workup revealed the presence of a scalp AVM that demonstrated extension into the left sigmoid sinus. Radiologic and intraoperative images are presented. Literature search revealed only 4 patients with scalp AVM extending intracranially into the sagittal sinus, 2 of which were managed with coagulation and division of the feeding vessels and the other 2 underwent preoperative embolization. Our patient is the 1st to be reported to have sigmoid sinus extension. Scalp AVMs with intracranial extension are rare, and require further preoperative workup. Following ultrasound evaluation, computed tomography angiography, magnetic resonance angiography, magnetic resonance imaging, or cerebral angiography can be considered. Treatment entails resection, but preoperative embolization is increasingly used, mirroring patients without intracranial extension. Further studies are needed to evaluate the efficacy and risk profile of these treatments.

Resection of an Embolized Cirsoid Aneurysm With Intracranial Venous Drainage: 2-Dimensional Operative Video.

Cirsoid aneurysms, also known as scalp arteriovenous malformations (AVM), are rare congenital extracranial vascular anomalies that often present as an enlarging pulsatile scalp mass. A 14-yr-old male presented with a pulsatile scalp lesion that was first noticed 3 yr prior and had progressively enlarged. No history of trauma was reported. MRI demonstrated a 4 cm wide and 2 cm tall nidus and catheter angiography was performed to further define the vascular supply and drainage. The patient underwent transvenous endovascular embolization followed by surgical excision via a bicoronal incision, as shown in this operative video. Care was taken to identify, cauterize, and transect feeding vessels from the superficial temporal, supratrochlear, and supraorbital arteries circumferentially to completely devascularize and resect the galeal nidus from overlying scalp tissue and underlying pericranium. Previously unreported in the literature, transosseous emissary veins partially draining the lesion were noted on angiography and were waxed thoroughly during surgery. Six-month follow-up examination demonstrated a well-healed incision without evidence of AVM recurrence. The unique venous drainage of this cirsoid aneurysm highlights the value of diagnostic angiography to fully characterize these rare and complex vascular lesions prior to pursuing definitive treatment.  IRB approval was obtained from the Ann & Robert H. Lurie Children's Hospital of Chicago Institutional Review Board (IRB #2018-1799). The IRB waives the requirement of obtaining informed consent for this study in accordance with 45 CFR 46.116(d).

Results of Endovascular-First Approach for Treatment of Scalp Arteriovenous Malformations and the Effect of Simplified Angiographic Classification in Therapeutic Decision-Making and Outcomes

Scalp arteriovenous malformation (SAVM) is primarily treated by surgery and reports on endovascular treatment are scarce. We report the results of an endovascular-first approach in the treatment of SAVM. We also have proposed a simple dichotomized classification using the angiographically determined morphology findings and discussed its effect on therapeutic decision-making and outcomes. A consecutive series of 25 patients with SAVM treated by initial or endovascular-only methods were included in the final analysis. The SAVM was categorized as a plexiform or fistulous type according to the angiographic morphology. The demographic data, treatment variables, and final clinical outcomes were analyzed and correlated with the proposed classification. Of the 25 patients, 21 were treated with n-butyl cyanoacrylate (n-BCA) and 3 with liquid ethylene vinyl alcohol. One patient had been treated initially with polyvinyl alcohol particles and later with n-BCA. Overall, complete or near complete obliteration (>90%) was achieved in 72%. Surgical excision was performed in 76%, most often after n-BCA embolization. Fistulous-type SAVMs required greater n-BCA concentrations (median, 33% vs. 20%; P= 0.024) and achieved greater rates of complete or near-complete obliteration (90% vs. 63%). Two patients with fistulous-type SAVMs treated with liquid ethylene vinyl alcohol showed complete resolution, and further treatment was not necessary. Overall, regardless of the embolic material used, the fistulous type demonstrated a significantly greater rate of complete obliteration (75% vs. 33%; P= 0.041) compared with plexiform type. High rates of complete and durable obliteration of SAVM are achievable with endovascular embolization. The proposed simplified classification is easy to implement and can aid in choosing the appropriate embolic agent and predicting the therapeutic outcome.

Scalp Arteriovenous Malformation (Cirsoid Aneurysm) in Adolescence: Report of 2 Cases and Review of the Literature

Scalp arteriovenous malformations, also known as cirsoid aneurysms, are rare lesions that are congenital, traumatic, or postinfectious in nature. These lesions may be found incidentally or owing to signs and symptoms that they produce, such as an enlarging pulsatile mass, headache, tinnitus, or bleeding. These lesions often constitute high-flow arterial blood from the superficial temporal or occipital arteries with venous outflow into extracranial venous structures. We describe diagnosis and management of 2 cases of congenital scalp arteriovenous malformations in adolescent patients. One case had more typical vascular supply and outflow, whereas the other case demonstrated more uncommon arterial blood supply from extracranial ophthalmic arteries as well as a component of transosseous venous drainage into the intracranial superior sagittal sinus via emissary veins. Treatment of these lesions usually consists of endovascular embolization followed by surgical resection. Both scalp AVMs described were successfully excised after transvenous embolization. Consideration of risks of intracranial venous drainage must be taken into account when evaluating AVM anatomy.

Congenital Neonatal scalp Arteriovenous Malformation, a very rare lesion.

Introduction: Congenital arteriovenous malformation (AVM) of scalp are rare congenital lesions to be reported. To date there is very scant data available on symptomatic congenital Scalp AVM in the neonatal population. They appear as red or purple birthmarks and are often mistaken as capillary hemangioma. We describe a case of symptomatic congenital arteriovenous malformation of scalp. Case-Report: A 10 days old baby boy was presented with an episode of profuse bleeding from a swelling at left temporal region of the scalp. Antenatal and birth history was …

Congenital Neonatal scalp Arteriovenous Malformation, a very rare lesion.

Congenital Neonatal scalp Arteriovenous Malformation, a very rare lesion.

Scalp arteriovenous malformation: A case report with review

Abstract Arteriovenous malformation (AVM) of the scalp is a rare lesion whose natural history remains to be elucidated. Clinical symptoms, usually, range from an asymptomatic lesion, local discomfort, headaches to necrosis and massive hemorrhage. Selective angiography remains the cornerstone for investigation. Complete surgical excision, embolization or an approach combining the modalities is curative. It can also cause massive hemorrhages due to dryness of the overlying skin and injuries. In this report we describe the clinical and radiological features of a patient with a scalp arteriovenous malformation.

Traumatic arteriovenous malformation of scalp: A case report

Scalp arteriovenous malformation (SAVM) as a rare lesion may be a complication of head injury. A case and its management are presented in this article and literature is reviewed. A 27-year-old man came to us with a slowly growing pulsatile mass in his right retroauricular and parietal region of the scalp. On examination, there was a compressible mass with loud bruit. Paraclinical studies revealed a large, tortuous tuft of vessels with two different feeders. Intracranial vessels were 3 normal. The lesion excised totally by direct surgical intervention after ligation of its feeders. The patient recovered and discharged without any abnormal findings. Increased number of reports of SAVM in the past decade may be due to improved diagnostic facilities; however, the high incidence of trauma and even its increasing pattern in developing countries may be another important factor.

Absolute Ethanol Embolization Combined with Surgical Resection of Scalp Arteriovenous Malformations: Interim Results

PurposeTo assess treatment methods, interim results, and complications of absolute ethanol embolization combined with surgical resection of scalp arteriovenous malformations (AVMs). Materials and MethodsFrom September 2012 to January 2015, 15 consecutive patients (8 male and 7 female) with scalp AVMs underwent staged ethanol embolizations. Ethanol embolization was performed using transcatheter and/or direct puncture techniques. Ten patients with scalp AVMs with a dominant outflow vein (DOV) also underwent coil deployment before ethanol embolization. Two patients underwent surgical resection after ethanol embolization was achieved. Follow-up evaluations included clinical outcome of symptoms and signs and imaging at 1.5 months, 6 months, and annually thereafter. ResultsIn 15 patients, 33 ethanol embolizations were performed; 16 coil deployments were performed in 10 patients who had scalp AVMs with a DOV. Of 15 patients, 8 (53.3%) were cured, 2 of whom underwent surgical resection. All 8 patients showed no recurrence in the follow-up period (range, 12–48 months; mean, 25 months). Seven patients (46.7%) had partial remission and will need further treatment sessions for residual AVMs (range, 1–12 months; mean, 7 months). In 3 of 15 patients (20%), 7 minor complications (skin blisters and necrosis) occurred. All minor complications healed with wound dressing and observation. There were no major complications. ConclusionsEthanol embolization has the potential for cure in management of scalp AVMs, with an acceptable risk of minor and major complications. Once AVMs are devascularized, surgical resection can be performed to improve cosmetic results.

Percutaneous Embolization of Scalp Arteriovenous Malformation Using New Liquid Embolic Agent, SQUID: A Technical Report

AbstractScalp arteriovenous malformations (AVMs) are rare extracranial vascular malformations that are traditionally treated by surgical excision or by combined endovascular-surgical approaches. We describe percutaneous treatment of scalp AVM, using a new liquid embolic agent, SQUID. Because of its nonadhesive property, prolonged injection and complete obliteration of scalp AVM is feasible. The cast formed is aesthetically appealing to the patient, and it may obviate the need for further surgical excision. It could be considered as the primary treatment option for patients unwilling for surgery.

Congenital neonatal scalp arteriovenous malformation: a very rare entity

Congenital arteriovenous malformations (AVMs) of scalp are rare congenital vascular malformations. They are usually not symptomatic at birth and are often misdiagnosed as haemangiomas. To date, only two cases of...