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|LETTER TO EDITOR
|Year : 2012 | Volume
| Issue : 4 | Page : 435-436
Non filling of scalp arteriovenous malformation: Effect of position
Manoj K Bhutte, Sudhir Suggala, Hukum Singh, Daljit Singh
Department of Neurosurgery, G B Pant Hospital, New Delhi, India
|Date of Web Publication||6-Sep-2012|
Department of Neurosurgery, G B Pant Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bhutte MK, Suggala S, Singh H, Singh D. Non filling of scalp arteriovenous malformation: Effect of position. Neurol India 2012;60:435-6
Scalp arteriovenous malformation (AVM) is an uncommon condition and normally presents with a boggy swelling, often pulsatile in nature. Though there is risk of bleeding, treatment is often for cosmetic reasons. The treatment options include surgical excision, endovascular procedure and or combinations. We present an interesting case of scalp AVM.
A 30-year-old female presented with progressive boggy swelling in the right occipital region of five years' duration. Digital subtraction angiography (DSA) revealed Type 1 scalp AVM  and was fed by the greater occipital artery [Figure 1]. Patient was taken for endovascular embolization 10 days after the diagnostic DSA. During therapeutic embolization, no AVM was seen [Figure 2]. Instead the feeding vessel appeared to be very narrow in its lumen. For a while it was thought that it might be a case of spontaneous occlusion of artery. A re-look at the patient's scalp suggested that the feeding artery was getting kinked by the head ring on which the patient's head was lying. The patient's head was tilted to the opposite side by 10 to 15 degrees which resulted in refilling of the scalp AVM. The feeding artery was selectively catheterized [Figure 3] and embolization with N butyl-cynoacrylate (NBCA) was completed. Check angiography showed no residual AVM [Figure 4]. The therapeutic disappearance of vascular lesion i.e. scalp AVM was only labeled when there was no visualization of AVM in different positions.
|Figure 2: Disappeared AVM with narrow feeding vessel (arrow) in supine|
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AVMs of the scalp consist of abnormally connecting arterial feeding vessels and draining veins, devoid of a normal capillary bed within the subcutaneous fatty layer of the scalp.  Most patients with scalp AVMs complain of headache, tinnitus and a subcutaneous (SC) mass with a palpable thrill. Enlargement of the mass over time can lead to worsening of these symptoms. Factors such as trauma, birth, and hormonal imbalance have been suggested as possible causes for the progression of these lesions.  They grow by having feeders from subcutaneous or intracranial vessels. The hemodynamic changes within the AVM can result in aneurysm formation. A few decades ago manual compression of the feeding artery used to be a method of treatment with an expectation of disappearance of scalp AVM over a period of time. However, the results were never encouraging. Various therapeutic modalities available to manage these lesions include: surgical excision, vessel ligation, transarterial and transvenous embolization, injection of sclerosant into the nidus, and electrothrombosis.  Scalp AVMs are generally treated by surgical excision. However, there is a risk of recurrence due to collateral supply. Surgical excision is associated with large skin incision, blood loss, and sometimes damage to the facial nerve. Endovascular treatment is used as an adjunct to the surgery or in isolation. Injection of the AVM has been done directly or by using ultrasound guidance. Embolization of AVM can be done using liquid embolizing material e.g. NBCA, ethanol or solid material like surgecele and gelfoam. Some authors have used a combination of trombin and transarterial coil placement. As there is no method which can avoid recurrence, the endovascular procedures have an edge due to their minimally invasive nature. There are three stages of scalp AVM.  Type 1 (a and b) and Type 2 are the most suitable AVMs for endovascular procedures.
| » References|| |
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|2.||Hage ZA, Few JW, Surdell DL, Adel JG, Batjer HH, Bendok BR. Modern endovascular and aesthetic surgery techniques to treat arteriovenous malformations of the scalp: Case illustration. Surg Neurol 2008;70:198-203. |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]