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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 3  |  Page : 357-358

Usefulness of computed tomographic angiography in the management of extracranial scalp arteriovenous malformation


Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha, India

Date of Submission15-Apr-2012
Date of Decision06-May-2012
Date of Acceptance14-May-2012
Date of Web Publication14-Jul-2012

Correspondence Address:
Souvagya Panigrahi
Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.98544

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How to cite this article:
Mishra SS, Panigrahi S, Parida D, Behera SK. Usefulness of computed tomographic angiography in the management of extracranial scalp arteriovenous malformation. Neurol India 2012;60:357-8

How to cite this URL:
Mishra SS, Panigrahi S, Parida D, Behera SK. Usefulness of computed tomographic angiography in the management of extracranial scalp arteriovenous malformation. Neurol India [serial online] 2012 [cited 2019 Aug 23];60:357-8. Available from: http://www.neurologyindia.com/text.asp?2012/60/3/357/98544


Sir,

Extracranial scalp arteriovenous malformations (AVMs) are relatively rare accounting for only 8.1% of cases. [1] They are 20 times more common in brain involving or supplied by intracranial vasculature. [2] We report a case of huge scalp AVM in a young lady and highlight the usefulness of computed tomographic angiography (CTA) in diagnosis and surgical management of scalp AVMs.

A 25-year-old lady presented with congenital left-sided painless scalp swelling. The swelling had been gradually increasing in size and since last 3 years it was of remarkable size causing cosmetic problem. On examination, a bluish, pulsatile, mobile swelling of 15 × 13 × 3 cm size with bruit was found over the left occipito-parietal region [Figure 1]a, b. Multidetector CTA of cerebral vasculature was performed by taking contiguous thin sections of 128 slices from arch of aorta up to skull vertex. It was done by intravenous injection of 100 ml of non-ionic contrast material (Iohexol 350 mg l/ml) at a rate of 4.5 ml/s by a power injector. Postprocessing multiplanar reconstruction showed the occipito-parietal scalp swelling to contain multiple tortuous dilated contrast filled vessels [Figure 2]. These were seen to form a racemose baggy network with simultaneous early filling of venous circulation in scalp indicating an arterovenous fistula. Left external carotid artery (ECA) was dilated. Feeding arteries with tortuous course appeared arising from the left superficial temporal artery and other branches of left ECA. Postprocessing 3 D-maximum intensity projection image showed normal intracranial circulation [Figure 3]. Prior to surgery, the feeding arteries as evidenced in CTA were ligated individually keeping one or more normal vessels intact to safeguard the vascularity of the scalp flap. During surgery, the feeding arteries were identified, ligated, and divided in between the base of the flap and the nidus making the AVM to devascularize. Then the AVM mass was excised [Figure 1]c. Prior ligation of feeders reduced intra-operative blood loss. Postoperative course was uneventful with no recurrence at 3-month follow-up. At discharge, she had improved cosmoses and without any evidence of bruit or thrill.
Figure 1: (a, b), The preoperative photograph demonstrates the extent of scalp AVM. (c) The excised AVM mass with dilated blood vessels

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Figure 2: CTA shaded surface display (SSD) images in posterior and left lateral projections showing dilated tortuous occipito-parietal vessels arising from left ECA with no underlying bony abnormality

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Figure 3: The 3D image with no bone (a) and maximum intensity projection image (b) showing dilated tortuous AVM of the left occipitoparietal vessels with normal intracranial circulation

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As the scalp has a rich arterial network fed by branches of ECA, the arterial system that supplies an AVM is frequently multiple and complex. Total excision of the extracranial malformation demands a complete knowledge of feeding arteries, the draining veins, and nidus of AVM. Thus, selective external and internal carotid angiographic studies are usually necessary. Catheter angiography has been the gold standard in imaging the neurovasculature. [3] However, it is expensive, invasive, time consuming, and requires high skill for intra-arterial manipulation of catheters with an associated risk of 1.5-2% morbidity and mortality. [4] On the other hand, recent developments of CT scanners with multislice technology have provided significant improvements in vascular applications allowing non-invasive evaluation. Advantages of CTA include shorter acquisition times, retrospective creation of thinner sections from source data, and improved 3D rendering with diminished artifacts. CTA can also provide a very high temporal resolution and the visualization of the related adjacent bony structures, which may be important in surgical planning. [5] In particular, it helps in identifying the feeding arteries that can be safely ligated individually prior to surgical excision of the AVM. Even though CTA has some limitations, such as contrast allergy and the lack of information about blood flow velocity and directionality, it can be used as a diagnostic alternative for extracranial and intracranial vascular diseases; more so in centers lacking DSA facilities such as ours. Management of scalp AVMs is difficult because of its high flow, complex vascular anatomy, and cosmetic problems. Among the various treatment options available, complete surgical excision is the most common and successful method of treating primary scalp AVMs. [1],[6] In conclusion, CTA is an excellent non-invasive and cheap method to visualize AVM. Complete excision accompanied or preceded by CTA-guided ligation of the feeding arteries is the treatment of choice for extracranial scalp AVM.

 
 » References Top

1.Huber P. Krayenbuhl/Yasargil cerebral angiography. 2 nd completely rev. ed. New York: Thieme Medical Publishers, Inc.; 1982. p. 373.  Back to cited text no. 1
    
2.Weinzweig N, Chin G, Polley J, Chabrel F, Shownkeen H, Debrun G. Arteriovenous malformation of the forehead, anterior scalp and nasal dorsum. Plast Reconstr Surg 2000;105:2433-9.  Back to cited text no. 2
    
3.Wilkinson HA. Recurrence of vascular malformation of the scalp 18 years following excision. Case report. J Neurosurg 1971;34:435-7.  Back to cited text no. 3
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4.Waugh JR, Sacharia N. Arteriographic complications in the DSA era. Radiology 1992;182:243-6.  Back to cited text no. 4
    
5.Teksam M, McKinney A, Truwit CL. Multi-slice CT angiography in evaluation of extracranial-intracranial bypass. Eur J Radiol 2004;52:217-20.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Shenoy SN, Raja A. Scalp arteriovenous malformations. Neurol India 2004;52:478-81.  Back to cited text no. 6
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3]

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