- Email: [email protected]
Cookie cutter technique for percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous malformations
Interdisciplinary Neurosurgery 20 (2020) 100677
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat
Technical notes & surgical techniques
Cookie cutter technique for percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous malformations
T
Saima Ahmad Pakistan Institute of Neurosciences, Neuroradiology Department, Lahore General Hospital, Ferozpur Road, Lahore, Pakistan
ABSTRACT
Background: Direct puncture embolization with glue is an effective technique for pre-operative devascularization of craniofacial arteriovenous malformations. Venous outflow and arterial inflow of the lesion need to be limited during injection of embolic material. Manual compression is the standard procedure for flow reduction, but when an AVM has multiple channels of venous drainage, achieving successful blockage of blood is technically difficult. This study demonstrates the use of a circumferential cookie cutter ring to reduce flow, with better results compared to manual compression. Design and methods: This is a retrospective study of ten patients, over a period of two years, with craniofacial arteriovenous malformations who were treated with direct percutaneous injection of glue. Pre-embolization angiography was performed to see arterial feeders and venous draining veins. Adjunctive maneuvers were used during embolization, including external compression of venous pouch with circular cookie cutter rings of different sizes varying based on lesion size. Glue cast was localized within and around the margins of circular cookie cutter ring without any distal migration. Results: No neurological complications secondary to the embolization procedure were observed. The arteriovenous shunts were successfully occluded in all cases. There was partial occlusion in two cases. Total occlusion achieved in five cases when embolization was followed by surgery. Only one case required a second session to achieve total occlusion. Post embolization, there was minimal residual flow in one patient, who declined further treatment due to mitigation of symptoms. The shape of glue cast was changed in two cases after removal of cookie cutter when low concentrated glue was used. No skin necrosis was seen post embolization. Conclusions: Percutaneous direct puncture embolization with glue saves time and is a safer method for superficial craniofacial AVMs with prominent venous pouch when external compression was applied with circumferential cookie cutters to reduce venous outflow.
1. Introduction A craniofacial arteriovenous deformity is an abnormal fistulous association between feeding artery and draining veins without an interceding capillary bed within the subcutaneous layer. (1) The draining veins are usually markedly dilated and may demonstrate variceal enlargement that isn't life threatening, however can cause cosmetic distortion (2). Usually, these lesions are treated by surgical excision or by combined endovascular-surgical approaches. (3) Due to ongoing development of endovascular procedures, better design of devices and improved embolization techniques, trans arterial and venous embolization of superficial craniofacial AVM has been utilized as preoperative ad juvant devascularization or as definitive treatment. However, embolization by means of arterial access might be insufficient, incomplete or technically difficult because of the presence of a complex vascular system, and might be fairly dangerous for important arterial compromise (for example ophthalmic artery branches), or may cause overlying skin ischemic necrosis. (4). Percutaneous direct puncture of the venous pouch is a more efficient method of access, and we used this technique because of the numerous advantages that it possesses in comparison to trans arterial embolization. Manual pressure of the draining vein is typically utilized for flow reduction. In case, when an AVM has multiple
channels of venous drainage, accomplishing successful blockage of blood flow is difficult with digital compression. (1) Using a cookie cutter for circumferential flow reduction can be more effective than manual digital compression (Figs. 1–4). The purpose of this study is to describe our experience with superficial craniofacial AVM in ten cases, and evaluate the outcome and benefits of percutaneous direct venous pouch puncture embolization with glue when adjunct with external compression by using cookie cutter ring. 2. Methods and materials From November 2016 to November 2018, 10 patients (4malesand6females) with a mean age of 22 years (minimum age of 14 years and maximum age of 37 years) underwent elective embolization with glue mixture using circular cookie cutter ring as a compression device for the treatment of high flow craniofacial arteriovenous malformations. The data of all patients described in Table 1. These patients were referred from plastic /reconstructive department for pain, swelling, thrill, tinnitus and cosmetic disfigurement. Four of these patients were previously treated with surgical excision and ligations but none of them had previous embolization’s.
E-mail address: [email protected]. https://doi.org/10.1016/j.inat.2020.100677 Received 9 December 2019; Received in revised form 22 January 2020; Accepted 2 February 2020 2214-7519/ © 2020 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
Fig. 1. (a)A 20-year-old female with a growing pulsatile mass and bruit caused by high flow arteriovenous malformation involving right periorbital region and nasal bridge.(b) Lateral projection of the right external carotid angiogram demonstrates a peri-orbital arteriovenous malformation supplied by branches of superficial temporal artery and internal maxillary artery draining into anterior jugular vein and supraorbital vein.(c) Lateral projection of the right internal carotid angiogram showing ophthalmic artery contribution to the supply of arteriovenous malformation.(d) Antero-posterior and lateral projection of left external carotid angiogram during second session embolization showing residual AVM filling from opposite side .(e) Lateral projection (f)The image was obtained after selective percutaneous puncture of draining vein.(g)Immediate post embolization image.(h)Post embolization selective left external carotid and right common carotid angiogram showing complete embolization of residual AVM. (i)Right common carotid angiogram post embolization.
Fig. 2. (a)A 37-year-old female with a growing pulsatile mass and bruit caused by long standing high flow arteriovenous malformation involving scalp, forehead (midline), right paraorbital region and nasal bridge. (b)Selective right external carotid angiogram showing hypertrophied superficial temporal artery feeding the AVM and dilated superficial scalp veins. (c)Unsubtracted angiogram during compression around the venous pouch by circular cookie cutter (d)Final right ICA & ECA angiogram obtained after glue embolization showed no residual shunt. (e) Follow up angiogram ECA (arterial & venous phase) obtained after 1 year of embolization showed very minimal residual AVM and glue cast. (f)Follow-up DSA after 1 year.
All of the underwent diagnostic angiography to include injections of bilateral external carotid arteries, bilateral internal carotid arteries and at least one vertebral artery via femoral approach to delineate the
feeding arteries and associated shunt. All of the treatments were performed after obtaining an informed consent. Percutaneous injections were performed by using 18-gauge 2
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
Fig. 3. (a)A 27-year-old female with a pulsatile mass and bruit caused by long standing high flow arteriovenous malformation over the scalp associated with headache, vomiting and bilateral tinnitus. (b)CT Brain (c)Lateral projection of right external carotid arteriogram revealing high flow scalp arteriovenous malformation supplying by middle meningeal artery and superficial temporal artery (arterial phase). (d)venous phase (e)Lateral projection of right internal carotid angiogram showing supply from ophthalmic artery. (f)The image captured during percutaneous embolization shows impediment of venous filling by the external compression over the vein with a hemostatic clamp.
needle or butterfly needle 22 gauge. External compression was applied in all cases by using the circular cookie cutter ring except in one case where the size of the lesion was large so haemostatic clamp was used to compress the outflow venous channel. In all patient’s glue mixture with iodized oil was given in different concentrations ranging from 40 to 60%. Migration of glue was closely monitored in all cases under fluoroscopic imaging.
was acquired to ensure whether the needle was in the nidus, venous pouch or in arterial feeder. The dilated venous pouch alongside the fistula is an ideal puncture site because focusing on the enlarged venous sac is generally simple and injected glue slowly regurgitate from the expanded vein into the fistula and after that into arterial feeder prompting total devascularization of the lesion while keeping effective pressure. In the event that the needle was safely situated inside the venous pouch, a 40–60% blend of n-BCA and iodized oil was injected amid compression at the skirt of the AVM by cookie cutter ring. The administrator kept up the pressure of the ring until complete polymerization of n-BCA and iodized oil mixture was achieved. Repeated punctures and n-BCA mixture were performed in those cases with bigger lesions. Movement of the glue was closely checked under fluoroscopy [1].
3. Embolization technique A specific pre procedure angiogram was acquired and analyzed for its anatomic details, including arterial supply, nidus and venous drainage. A similar angiography (compression angiography) was repeated after the circular cookie cutter was placed at the border of the venous pouch and it compressed the lesion. Compression was viewed as perfect when the compression angiogram revealed the stasis of flow inside the limit of the circular cookie cutter ring without showing venous drainage outside the ring. It was important to modify the compression force while acquiring the compression angiogram to appropriately compress the veins but not compress the arterial supply totally to prevent blockage of the inflow. When the position of the ring and the degree of compression was determined, direct puncture with an 18-gauge needle was done. In one case we utilized butterfly needle as the lesion was small in size. At the point where the needle was inserted into the lesion and blood was returned through the needle, an immediate direct puncture angiogram
4. Results The data of all patients is summarised in Table 1. Seven patient had scalp lesions, and two had paraorbital regional involvement. One patient had a nasal bridge involved. In yet another patient there were two lesions on the scalp and one at the pinna. On pre embolization angiography all lesions had multiple feeders and draining veins. All patients were treated under general anaesthesia. In all patients, a dilated venous pouch and multiple sites of arteriovenous communication were identified. There was intracranial involvement in two of the total cases. All ten lesions were treated with percutaneous direct 3
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
Fig. 4. (a)A 25-year-old female with a pulsatile swelling over post auricular region overlying scalp. (b)Lateral projection of left common angiogram showing large arteriovenous angiogram supplying through occipital artery and posterior auricular artery draining into external jugular vein. (c)Image obtained during the compression around the venous pouch by cookie cutter, contrast medium stagnates within the circular ring margins. (d)Post embolization ipsilateral external carotid angiogram demonstrating significant reduction in flow after first session. (e)Lateral subtraction Angiogram during embolization. (f)Unsubtracted native image obtained post embolization showing glue cast.
puncture embolization with nBCA using circumferential cookie cutter ring for compression of venous outflow. No procedure related complication or necrosis was seen in any of the case. Post embolization angiograms revealed that the lesions in all ten patients had significantly and successfully been embolized after glue injection. No glue retrograde reflux into feeding arteries occurred in any of the cases nor was there any distal draining vein migration due to effective compression by cookie cutter. All patients experienced pain and swelling post embolization due to NBCA which settled post procedure. The NBCA caste in the superficial lesions was subsequently resected by surgery for cosmetic reasons and only minimal intraoperative bleeding was reported.
frontal, temporal and parietal areas. The principle sources of blood supply to the scalp are situated in the subcutaneous tissue and derived from the external carotid, occipital and supraorbital arteries. The superficial temporal artery is often involved in traumatic scalp AVM because of its long uncovered course. The etiology of these lesions is still unknown. That said, it is commonly acknowledged that it might be congenital or traumatic in origin. Roughly 10 to 20% of scalp arteriovenous malformations formed following penetrating or non-penetrating injury to the scalp and forehead [5]. The clinical presentation of scalp AVM may change from benign features, for example, pulsatile swelling and tinnitus to dangerous symptoms, for example, perilous hemorrhage and scalp necrosis. The indications for treatment include intermittent or massive hemorrhage from the AVM, troublesome symptoms, or cosmetic concerns. Generally, the scalp AVMs have been treated by surgery that included radical and careful excision and feeding artery ligation. The surgical procedure is often complicated by major intraoperative bleeding and the surgeon endeavors to accomplish hemostasis by ligating the feeding artery, tourniquets, or clamps. Inadequate excision results in residual or recurrent AVMs and further complicates future surgical or endovascular
5. Discussion The vascular malformations of the scalp and forehead is an abnormal arteriovenous communication present within the subcutaneous fatty layer of the scalp and forehead with the feeding arteries driven from the vessels supplying the scalp. The area of scalp and forehead arteriovenous fistulas is generally uniformly distributed among the 4
Interdisciplinary Neurosurgery 20 (2020) 100677 Total removal after single session embolization followed by surgery 50% Angular vein and facial vein
Bilateral superficial temporal arteries, posterior auricular artery bilateral superficial temporal arteries
50%
80% embolization after single session of embolization
treatment. Likewise, scalp reconstruction is an imperative consideration when the surgical defect is large [3]. In contrast to the intracranial circulation, craniofacial high-flow AVMSs are uncommon, and there is no gold standard treatment method. Embolization has become a vital part of the treatment of these malformations. Cure of these lesions might be accomplished by embolization alone or embolization followed by surgical excision. Fistulous lesions are likely to be cured by embolization alone through an IA or potentially direct percutaneous approach [6]. Percutaneous direct puncture embolization is a powerful, efficient and safe method for the preoperative devascularization of superficial craniofacial AVM with prominent venous pouch. Compared with the trans arterial route, direct puncture technique has the benefit of reducing the danger of skin ischemia and compromise of central retinal artery. It can diminish the likelihood of partial embolization and result in a later recruit of new collateral feeders. The impact is dramatic and quick in symptom relief and intraoperative bleeding control. For cosmetic consideration, there is no danger of skin necrosis and the lesion can be resected without the requirement for a skin graft [4]. Scalp AVMs are more averse to communicate with the deep venous system on account of their superficial locations. Consequently, manual compressions were performed of venous drainage amid glue injection to diminish unwanted washout into the distal venous outflow. To stay away from exposure of the administrator's hand to radiation or temporary occlusion of the venous outflow, a ring-shaped compression device can be utilized. In case, if there is an AVM with complex venous drainage, complete occlusion of the venous outflow with a simple device is challenging [2]. Compression of the draining veins with liquid embolic agents is important to decrease complications arising from distal migration such as pulmonary embolism and occlusion of normal venous drainage. External band ligation, manual compression, and circular ring compression devices have been described [7]. At our institution we utilized multiple sized circumferential cookie cutter rings for external compression of venous pouch during percutaneous injection of glue for AVMs and found it to be more effective and safe as compare to other techniques. 6. Conclusion:
Nil
Our study showed that percutaneous direct puncture embolization with glue was more time effective and safer for superficial craniofacial AVMs. The study had an equal mix of males and females and generally patients were of young age with a mean age of 22. Out of our ten patients the new cookie cutter technique was effective for trapping the glue mixture within the venous sac of the craniofacial high flow AVM and for occluding the AV shunt. It avoids several limitations associated with other therapeutic options and can be considered as the primary treatment option for patients unwilling to undergo surgery. There was less bleeding and the procedure was simpler compared to surgery. Furthermore, due to procedure, surgery was often times avoided and in the case of surgery still being required there was minimal bleeding and skin grafting was not required in any of the cases. Declaration of Competing Interest
Scalp
Scalp
30Y/M
14Y/M 10
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.inat.2020.100677.
9
Scalp 24Y/F
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Appendix A. Supplementary data
8
17Y/F 7
37Y/F 6
Previous surgery
50% Superificial temporal artery ,ophthalmic artery
40%
Superficial scalp veins ,internal jugular vein supratrochlear vein ,superficial scalp vein bilateral superficial temporal veins occipital artery,superficial temporal artery
Previous surgery & ligation Previous surgery & ligation Nil
50%
superficial scalp veins, internal jugular vein , angular vein Superficial scalp veins internal maxillary artery, superficial temporal artery, ophthalmic artery Superficial temporal artery (both branches) Nil 5
20Y/F
Paraorbital , nose bridge Scalp ,forehead ,paraorbital Scalp ,Pinna
50%
50% superficial scalp veins Occipital artery Nil Scalp 4
27Y/M
50% 60% Scalp Scalp 2 3
25Y/F 30Y/M
Superficial scalp veins superficial scalp veins
Total removal after single session of embolization followed by surgery. 75% embolized after single embolization. Total removal after single session embolization followed by surgery Total removal after single session of embolization followed by surgery. Complete embolizaton after two sessions of embolizations, patient refused surgery for cosmetic reasons. 95% embolizations after single session embolization ,patient refused embolization and surgery afterwards Total removal after 60% embolization in single session followed by surgery Residual AVM 50% Superficial scalp veins
Occipital artery, superficial temporal artery ,ophthalmic artery Occipital artery ,middle meningeal artery Superificial temporal artery ,occipital artery Previously surgery done Nil Post traumatic Scalp 1
27Y/F
Draining Vein Feeding Artery Trauma/Surgery History Location Age/Sex No
Table 1 Clinical characteristics, angiographic findings and embolization profiles.
nBCA concentration
Outcome
S. Ahmad
5
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
References
[4] C.H. Ou, H.F. Wong, M.S. Yang, T.H. Yang, T.L. Ho, Percutaneous direct puncture embolization for superficial craniofacial arteriovenous malformation, Int. Neuroradiol. 14 (2_suppl) (2008) 19–22. [5] S.N. Shenoy, A. Raja, Scalp arteriovenous malformations, Neurol. India 52 (4) (2004) 478. [6] A. Arat, B.E. Cil, I. Vargel, B. Turkbey, M. Canyigit, B. Peynircioglu, Y.O. Arat, Embolization of high-flow craniofacial vascular malformations with onyx, Am. J. Neuroradiol. 28 (7) (2007) 1409–1414. [7] B.B. Lee, I. Baumgartner, H.P. Berlien, G. Bianchini, P. Burrows, Y.S. Do, J.C. LopezGutierrez, Consensus document of the International Union of Angiology (IUA)-2013. Current concepts on the management of arterio-venous malformations, Int. Angiol. 32 (1) (2013) 9–36.
[1] C.W. Ryu, S.M. Whang, D.C. Suh, S.M. Kim, Y.J. Jang, H.J. Kim, S.J. Kim, Percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous lesions: a new circular ring compression device with a beveled edge, Am. J. Neuroradiol. 28 (3) (2007) 528–530. [2] K.M. Lee, E.J. Kim, B.J. Park, K.H. Kim, Direct puncture embolization of scalp arteriovenous malformation in a patient with severe hemophilia A: a case report, J. Kor. Soc. Radiol. 65 (3) (2011) 229–233. [3] S.K. Kannath, J.E. Rajan, Percutaneous embolization of scalp arteriovenous malformation using new liquid embolic agent, SQUID: A Technical Report, J. Clin. Intervent. Radiol. ISVIR 1 (03) (2017) 171–174.
6
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat
Technical notes & surgical techniques
Cookie cutter technique for percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous malformations
T
Saima Ahmad Pakistan Institute of Neurosciences, Neuroradiology Department, Lahore General Hospital, Ferozpur Road, Lahore, Pakistan
ABSTRACT
Background: Direct puncture embolization with glue is an effective technique for pre-operative devascularization of craniofacial arteriovenous malformations. Venous outflow and arterial inflow of the lesion need to be limited during injection of embolic material. Manual compression is the standard procedure for flow reduction, but when an AVM has multiple channels of venous drainage, achieving successful blockage of blood is technically difficult. This study demonstrates the use of a circumferential cookie cutter ring to reduce flow, with better results compared to manual compression. Design and methods: This is a retrospective study of ten patients, over a period of two years, with craniofacial arteriovenous malformations who were treated with direct percutaneous injection of glue. Pre-embolization angiography was performed to see arterial feeders and venous draining veins. Adjunctive maneuvers were used during embolization, including external compression of venous pouch with circular cookie cutter rings of different sizes varying based on lesion size. Glue cast was localized within and around the margins of circular cookie cutter ring without any distal migration. Results: No neurological complications secondary to the embolization procedure were observed. The arteriovenous shunts were successfully occluded in all cases. There was partial occlusion in two cases. Total occlusion achieved in five cases when embolization was followed by surgery. Only one case required a second session to achieve total occlusion. Post embolization, there was minimal residual flow in one patient, who declined further treatment due to mitigation of symptoms. The shape of glue cast was changed in two cases after removal of cookie cutter when low concentrated glue was used. No skin necrosis was seen post embolization. Conclusions: Percutaneous direct puncture embolization with glue saves time and is a safer method for superficial craniofacial AVMs with prominent venous pouch when external compression was applied with circumferential cookie cutters to reduce venous outflow.
1. Introduction A craniofacial arteriovenous deformity is an abnormal fistulous association between feeding artery and draining veins without an interceding capillary bed within the subcutaneous layer. (1) The draining veins are usually markedly dilated and may demonstrate variceal enlargement that isn't life threatening, however can cause cosmetic distortion (2). Usually, these lesions are treated by surgical excision or by combined endovascular-surgical approaches. (3) Due to ongoing development of endovascular procedures, better design of devices and improved embolization techniques, trans arterial and venous embolization of superficial craniofacial AVM has been utilized as preoperative ad juvant devascularization or as definitive treatment. However, embolization by means of arterial access might be insufficient, incomplete or technically difficult because of the presence of a complex vascular system, and might be fairly dangerous for important arterial compromise (for example ophthalmic artery branches), or may cause overlying skin ischemic necrosis. (4). Percutaneous direct puncture of the venous pouch is a more efficient method of access, and we used this technique because of the numerous advantages that it possesses in comparison to trans arterial embolization. Manual pressure of the draining vein is typically utilized for flow reduction. In case, when an AVM has multiple
channels of venous drainage, accomplishing successful blockage of blood flow is difficult with digital compression. (1) Using a cookie cutter for circumferential flow reduction can be more effective than manual digital compression (Figs. 1–4). The purpose of this study is to describe our experience with superficial craniofacial AVM in ten cases, and evaluate the outcome and benefits of percutaneous direct venous pouch puncture embolization with glue when adjunct with external compression by using cookie cutter ring. 2. Methods and materials From November 2016 to November 2018, 10 patients (4malesand6females) with a mean age of 22 years (minimum age of 14 years and maximum age of 37 years) underwent elective embolization with glue mixture using circular cookie cutter ring as a compression device for the treatment of high flow craniofacial arteriovenous malformations. The data of all patients described in Table 1. These patients were referred from plastic /reconstructive department for pain, swelling, thrill, tinnitus and cosmetic disfigurement. Four of these patients were previously treated with surgical excision and ligations but none of them had previous embolization’s.
E-mail address: [email protected]. https://doi.org/10.1016/j.inat.2020.100677 Received 9 December 2019; Received in revised form 22 January 2020; Accepted 2 February 2020 2214-7519/ © 2020 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
Fig. 1. (a)A 20-year-old female with a growing pulsatile mass and bruit caused by high flow arteriovenous malformation involving right periorbital region and nasal bridge.(b) Lateral projection of the right external carotid angiogram demonstrates a peri-orbital arteriovenous malformation supplied by branches of superficial temporal artery and internal maxillary artery draining into anterior jugular vein and supraorbital vein.(c) Lateral projection of the right internal carotid angiogram showing ophthalmic artery contribution to the supply of arteriovenous malformation.(d) Antero-posterior and lateral projection of left external carotid angiogram during second session embolization showing residual AVM filling from opposite side .(e) Lateral projection (f)The image was obtained after selective percutaneous puncture of draining vein.(g)Immediate post embolization image.(h)Post embolization selective left external carotid and right common carotid angiogram showing complete embolization of residual AVM. (i)Right common carotid angiogram post embolization.
Fig. 2. (a)A 37-year-old female with a growing pulsatile mass and bruit caused by long standing high flow arteriovenous malformation involving scalp, forehead (midline), right paraorbital region and nasal bridge. (b)Selective right external carotid angiogram showing hypertrophied superficial temporal artery feeding the AVM and dilated superficial scalp veins. (c)Unsubtracted angiogram during compression around the venous pouch by circular cookie cutter (d)Final right ICA & ECA angiogram obtained after glue embolization showed no residual shunt. (e) Follow up angiogram ECA (arterial & venous phase) obtained after 1 year of embolization showed very minimal residual AVM and glue cast. (f)Follow-up DSA after 1 year.
All of the underwent diagnostic angiography to include injections of bilateral external carotid arteries, bilateral internal carotid arteries and at least one vertebral artery via femoral approach to delineate the
feeding arteries and associated shunt. All of the treatments were performed after obtaining an informed consent. Percutaneous injections were performed by using 18-gauge 2
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
Fig. 3. (a)A 27-year-old female with a pulsatile mass and bruit caused by long standing high flow arteriovenous malformation over the scalp associated with headache, vomiting and bilateral tinnitus. (b)CT Brain (c)Lateral projection of right external carotid arteriogram revealing high flow scalp arteriovenous malformation supplying by middle meningeal artery and superficial temporal artery (arterial phase). (d)venous phase (e)Lateral projection of right internal carotid angiogram showing supply from ophthalmic artery. (f)The image captured during percutaneous embolization shows impediment of venous filling by the external compression over the vein with a hemostatic clamp.
needle or butterfly needle 22 gauge. External compression was applied in all cases by using the circular cookie cutter ring except in one case where the size of the lesion was large so haemostatic clamp was used to compress the outflow venous channel. In all patient’s glue mixture with iodized oil was given in different concentrations ranging from 40 to 60%. Migration of glue was closely monitored in all cases under fluoroscopic imaging.
was acquired to ensure whether the needle was in the nidus, venous pouch or in arterial feeder. The dilated venous pouch alongside the fistula is an ideal puncture site because focusing on the enlarged venous sac is generally simple and injected glue slowly regurgitate from the expanded vein into the fistula and after that into arterial feeder prompting total devascularization of the lesion while keeping effective pressure. In the event that the needle was safely situated inside the venous pouch, a 40–60% blend of n-BCA and iodized oil was injected amid compression at the skirt of the AVM by cookie cutter ring. The administrator kept up the pressure of the ring until complete polymerization of n-BCA and iodized oil mixture was achieved. Repeated punctures and n-BCA mixture were performed in those cases with bigger lesions. Movement of the glue was closely checked under fluoroscopy [1].
3. Embolization technique A specific pre procedure angiogram was acquired and analyzed for its anatomic details, including arterial supply, nidus and venous drainage. A similar angiography (compression angiography) was repeated after the circular cookie cutter was placed at the border of the venous pouch and it compressed the lesion. Compression was viewed as perfect when the compression angiogram revealed the stasis of flow inside the limit of the circular cookie cutter ring without showing venous drainage outside the ring. It was important to modify the compression force while acquiring the compression angiogram to appropriately compress the veins but not compress the arterial supply totally to prevent blockage of the inflow. When the position of the ring and the degree of compression was determined, direct puncture with an 18-gauge needle was done. In one case we utilized butterfly needle as the lesion was small in size. At the point where the needle was inserted into the lesion and blood was returned through the needle, an immediate direct puncture angiogram
4. Results The data of all patients is summarised in Table 1. Seven patient had scalp lesions, and two had paraorbital regional involvement. One patient had a nasal bridge involved. In yet another patient there were two lesions on the scalp and one at the pinna. On pre embolization angiography all lesions had multiple feeders and draining veins. All patients were treated under general anaesthesia. In all patients, a dilated venous pouch and multiple sites of arteriovenous communication were identified. There was intracranial involvement in two of the total cases. All ten lesions were treated with percutaneous direct 3
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
Fig. 4. (a)A 25-year-old female with a pulsatile swelling over post auricular region overlying scalp. (b)Lateral projection of left common angiogram showing large arteriovenous angiogram supplying through occipital artery and posterior auricular artery draining into external jugular vein. (c)Image obtained during the compression around the venous pouch by cookie cutter, contrast medium stagnates within the circular ring margins. (d)Post embolization ipsilateral external carotid angiogram demonstrating significant reduction in flow after first session. (e)Lateral subtraction Angiogram during embolization. (f)Unsubtracted native image obtained post embolization showing glue cast.
puncture embolization with nBCA using circumferential cookie cutter ring for compression of venous outflow. No procedure related complication or necrosis was seen in any of the case. Post embolization angiograms revealed that the lesions in all ten patients had significantly and successfully been embolized after glue injection. No glue retrograde reflux into feeding arteries occurred in any of the cases nor was there any distal draining vein migration due to effective compression by cookie cutter. All patients experienced pain and swelling post embolization due to NBCA which settled post procedure. The NBCA caste in the superficial lesions was subsequently resected by surgery for cosmetic reasons and only minimal intraoperative bleeding was reported.
frontal, temporal and parietal areas. The principle sources of blood supply to the scalp are situated in the subcutaneous tissue and derived from the external carotid, occipital and supraorbital arteries. The superficial temporal artery is often involved in traumatic scalp AVM because of its long uncovered course. The etiology of these lesions is still unknown. That said, it is commonly acknowledged that it might be congenital or traumatic in origin. Roughly 10 to 20% of scalp arteriovenous malformations formed following penetrating or non-penetrating injury to the scalp and forehead [5]. The clinical presentation of scalp AVM may change from benign features, for example, pulsatile swelling and tinnitus to dangerous symptoms, for example, perilous hemorrhage and scalp necrosis. The indications for treatment include intermittent or massive hemorrhage from the AVM, troublesome symptoms, or cosmetic concerns. Generally, the scalp AVMs have been treated by surgery that included radical and careful excision and feeding artery ligation. The surgical procedure is often complicated by major intraoperative bleeding and the surgeon endeavors to accomplish hemostasis by ligating the feeding artery, tourniquets, or clamps. Inadequate excision results in residual or recurrent AVMs and further complicates future surgical or endovascular
5. Discussion The vascular malformations of the scalp and forehead is an abnormal arteriovenous communication present within the subcutaneous fatty layer of the scalp and forehead with the feeding arteries driven from the vessels supplying the scalp. The area of scalp and forehead arteriovenous fistulas is generally uniformly distributed among the 4
Interdisciplinary Neurosurgery 20 (2020) 100677 Total removal after single session embolization followed by surgery 50% Angular vein and facial vein
Bilateral superficial temporal arteries, posterior auricular artery bilateral superficial temporal arteries
50%
80% embolization after single session of embolization
treatment. Likewise, scalp reconstruction is an imperative consideration when the surgical defect is large [3]. In contrast to the intracranial circulation, craniofacial high-flow AVMSs are uncommon, and there is no gold standard treatment method. Embolization has become a vital part of the treatment of these malformations. Cure of these lesions might be accomplished by embolization alone or embolization followed by surgical excision. Fistulous lesions are likely to be cured by embolization alone through an IA or potentially direct percutaneous approach [6]. Percutaneous direct puncture embolization is a powerful, efficient and safe method for the preoperative devascularization of superficial craniofacial AVM with prominent venous pouch. Compared with the trans arterial route, direct puncture technique has the benefit of reducing the danger of skin ischemia and compromise of central retinal artery. It can diminish the likelihood of partial embolization and result in a later recruit of new collateral feeders. The impact is dramatic and quick in symptom relief and intraoperative bleeding control. For cosmetic consideration, there is no danger of skin necrosis and the lesion can be resected without the requirement for a skin graft [4]. Scalp AVMs are more averse to communicate with the deep venous system on account of their superficial locations. Consequently, manual compressions were performed of venous drainage amid glue injection to diminish unwanted washout into the distal venous outflow. To stay away from exposure of the administrator's hand to radiation or temporary occlusion of the venous outflow, a ring-shaped compression device can be utilized. In case, if there is an AVM with complex venous drainage, complete occlusion of the venous outflow with a simple device is challenging [2]. Compression of the draining veins with liquid embolic agents is important to decrease complications arising from distal migration such as pulmonary embolism and occlusion of normal venous drainage. External band ligation, manual compression, and circular ring compression devices have been described [7]. At our institution we utilized multiple sized circumferential cookie cutter rings for external compression of venous pouch during percutaneous injection of glue for AVMs and found it to be more effective and safe as compare to other techniques. 6. Conclusion:
Nil
Our study showed that percutaneous direct puncture embolization with glue was more time effective and safer for superficial craniofacial AVMs. The study had an equal mix of males and females and generally patients were of young age with a mean age of 22. Out of our ten patients the new cookie cutter technique was effective for trapping the glue mixture within the venous sac of the craniofacial high flow AVM and for occluding the AV shunt. It avoids several limitations associated with other therapeutic options and can be considered as the primary treatment option for patients unwilling to undergo surgery. There was less bleeding and the procedure was simpler compared to surgery. Furthermore, due to procedure, surgery was often times avoided and in the case of surgery still being required there was minimal bleeding and skin grafting was not required in any of the cases. Declaration of Competing Interest
Scalp
Scalp
30Y/M
14Y/M 10
Supplementary data to this article can be found online at https:// doi.org/10.1016/j.inat.2020.100677.
9
Scalp 24Y/F
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Appendix A. Supplementary data
8
17Y/F 7
37Y/F 6
Previous surgery
50% Superificial temporal artery ,ophthalmic artery
40%
Superficial scalp veins ,internal jugular vein supratrochlear vein ,superficial scalp vein bilateral superficial temporal veins occipital artery,superficial temporal artery
Previous surgery & ligation Previous surgery & ligation Nil
50%
superficial scalp veins, internal jugular vein , angular vein Superficial scalp veins internal maxillary artery, superficial temporal artery, ophthalmic artery Superficial temporal artery (both branches) Nil 5
20Y/F
Paraorbital , nose bridge Scalp ,forehead ,paraorbital Scalp ,Pinna
50%
50% superficial scalp veins Occipital artery Nil Scalp 4
27Y/M
50% 60% Scalp Scalp 2 3
25Y/F 30Y/M
Superficial scalp veins superficial scalp veins
Total removal after single session of embolization followed by surgery. 75% embolized after single embolization. Total removal after single session embolization followed by surgery Total removal after single session of embolization followed by surgery. Complete embolizaton after two sessions of embolizations, patient refused surgery for cosmetic reasons. 95% embolizations after single session embolization ,patient refused embolization and surgery afterwards Total removal after 60% embolization in single session followed by surgery Residual AVM 50% Superficial scalp veins
Occipital artery, superficial temporal artery ,ophthalmic artery Occipital artery ,middle meningeal artery Superificial temporal artery ,occipital artery Previously surgery done Nil Post traumatic Scalp 1
27Y/F
Draining Vein Feeding Artery Trauma/Surgery History Location Age/Sex No
Table 1 Clinical characteristics, angiographic findings and embolization profiles.
nBCA concentration
Outcome
S. Ahmad
5
Interdisciplinary Neurosurgery 20 (2020) 100677
S. Ahmad
References
[4] C.H. Ou, H.F. Wong, M.S. Yang, T.H. Yang, T.L. Ho, Percutaneous direct puncture embolization for superficial craniofacial arteriovenous malformation, Int. Neuroradiol. 14 (2_suppl) (2008) 19–22. [5] S.N. Shenoy, A. Raja, Scalp arteriovenous malformations, Neurol. India 52 (4) (2004) 478. [6] A. Arat, B.E. Cil, I. Vargel, B. Turkbey, M. Canyigit, B. Peynircioglu, Y.O. Arat, Embolization of high-flow craniofacial vascular malformations with onyx, Am. J. Neuroradiol. 28 (7) (2007) 1409–1414. [7] B.B. Lee, I. Baumgartner, H.P. Berlien, G. Bianchini, P. Burrows, Y.S. Do, J.C. LopezGutierrez, Consensus document of the International Union of Angiology (IUA)-2013. Current concepts on the management of arterio-venous malformations, Int. Angiol. 32 (1) (2013) 9–36.
[1] C.W. Ryu, S.M. Whang, D.C. Suh, S.M. Kim, Y.J. Jang, H.J. Kim, S.J. Kim, Percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous lesions: a new circular ring compression device with a beveled edge, Am. J. Neuroradiol. 28 (3) (2007) 528–530. [2] K.M. Lee, E.J. Kim, B.J. Park, K.H. Kim, Direct puncture embolization of scalp arteriovenous malformation in a patient with severe hemophilia A: a case report, J. Kor. Soc. Radiol. 65 (3) (2011) 229–233. [3] S.K. Kannath, J.E. Rajan, Percutaneous embolization of scalp arteriovenous malformation using new liquid embolic agent, SQUID: A Technical Report, J. Clin. Intervent. Radiol. ISVIR 1 (03) (2017) 171–174.
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