neurointervention.org Open in urlscan Pro
121.254.129.109  Public Scan

Form analysis
2 forms found in the DOM

Name: searformform — POST /articles/search_result.php

<form name="searformform" method="post" action="/articles/search_result.php" onsubmit="return transText(this);">
  <fieldset>
    <legend>Neurointervention Search</legend>
    <input type="text" name="term_all" autocomplete="off" value="" placeholder="Keyword, Title, Author, or Citation" class="_placeholder" onkeyup="autoCompleteHead(this.value);" onfocus="autoCompleteHead(this.value);" onblur="term_all_onblur();">
    <span class="search"><input class="opacity0" type="submit" value="Search"></span>
  </fieldset>
</form>

POST //translate.googleapis.com/translate_voting?client=te

<form id="goog-gt-votingForm" action="//translate.googleapis.com/translate_voting?client=te" method="post" target="votingFrame" class="VIpgJd-yAWNEb-hvhgNd-aXYTce"><input type="text" name="sl" id="goog-gt-votingInputSrcLang"><input type="text"
    name="tl" id="goog-gt-votingInputTrgLang"><input type="text" name="query" id="goog-gt-votingInputSrcText"><input type="text" name="gtrans" id="goog-gt-votingInputTrgText"><input type="text" name="vote" id="goog-gt-votingInputVote"></form>

Text Content

 * Home
 * E-submission
 * Sitemap
 * Contact us
 * ▼


 * HOME
 * ABOUT
   * Aim and scope
   * About the journal
   * Editorial board
   * Best practice
   * Open access
   * Contact us
 * ARTICLE CATEGORY 
    * Editorial
    * Review
    * Original Paper
    * Case Report
    * Letter to Editor
   
   Browse all articles >

 * BROWSE ARTICLES 
    * Current issue
    * All issues
    * Ahead-of print
    * Most viewed
    * Most download
    * Most cited
    * Funded articles
    * Neurointervention Search
    * Author index

   
 * AUTHOR INFORMATION 
   * Instructions for authors
   * Research and publication ethics
   * E-submission
   * Author’s checklist
   * Copyright transfer agreement
   * Conflict of interest disclosure form

 * 
 * 

Search
Neurointervention Search


CLOSE

--------------------------------------------------------------------------------

Neurointervention > Volume 19(3); 2024 > Article


Kim and Suh: Endovascular Treatment of Scalp Arteriovenous Fistula: Transvenous
Onyx Embolization with Balloon Occlusion

Technical Note



Neurointervention 2024;19(3):169-173.

Print publication date: November 2024

Published online: October 11, 2024

DOI: https://doi.org/10.5469/neuroint.2024.00374






ENDOVASCULAR TREATMENT OF SCALP ARTERIOVENOUS FISTULA: TRANSVENOUS ONYX
EMBOLIZATION WITH BALLOON OCCLUSION

Taemin Kim, MD, Sang Hyun Suh, MD, PhD

Department of Radiology, Gangnam Severance Hospital, Yonsei University College
of Medicine, Seoul, Korea

Correspondence to: Sang Hyun Suh, MD, PhD Department of Radiology, Gangnam
Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro,
Gangnam-gu, Seoul 06273, Korea
Tel: +82-2-2019-3510 Fax: +82-2-3462-5472 E-mail: suhsh11@yuhs.ac



Received August 26, 2024       Revised September 25, 2024       Accepted
September 25, 2024

Copyright © 2024 Korean Society of Interventional Neuroradiology

This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.



ABSTRACT

Scalp arteriovenous fistulas (AVFs) are rare vascular anomalies characterized by
abnormal connections between arterial and venous systems in the scalp. These
lesions can lead to significant complications, including chronic headaches,
tinnitus, cosmetic deformities, and in severe cases, high-output cardiac failure
or intracranial hemorrhage. We present a case of a middle-aged female patient
with a 20-year history of a pulsating mass on the left parietal scalp. Magnetic
resonance imaging and cerebral angiography confirmed the presence of a scalp AVF
with multiple arterial feeders from the external carotid artery and venous
drainage into the left external jugular vein. Due to the tortuosity of the
feeding arteries, a transarterial approach was unsuccessful, leading to the
decision to perform transvenous embolization with balloon occlusion using
Onyx-18. The procedure resulted in complete obliteration of the AVF without
complications. This case highlights the efficacy of transvenous embolization
with balloon occlusion as a treatment option for complex scalp AVFs,
particularly when transarterial access is challenging.



Key Words: Scalp; Arteriovenous fistula; Embolization; Balloon occlusion; Veins

Go to :



INTRODUCTION

Scalp arteriovenous fistulas (AVFs) are rare vascular anomalies characterized by
abnormal connections between the arterial and venous systems within the scalp.
These lesions can be congenital or acquired, with trauma and surgical
interventions being the most common etiologies in adults [1-9]. Although scalp
AVFs are uncommon, their clinical significance is substantial due to the
potential for serious complications, including chronic headaches, tinnitus,
cosmetic deformities, and, in severe cases, high-output cardiac failure or
intracranial hemorrhage [3,10].
Current treatment strategies for scalp AVFs include endovascular embolization,
surgical ligation, or a combination of both [11-17]. The choice of treatment is
guided by the characteristics of the scalp AVF [18]. In this report, we present
a case of scalp AVF that underwent transvenous embolization with balloon
occlusion and Onyx (Medtronic).
Go to :



CASE REPORT

A middle-aged female patient was admitted to the hospital, presenting with a
pulsating mass on the left parietal scalp area for 20 years. She had no history
of trauma or surgical procedure. Physical examination revealed a soft, tender,
and pulsatile subcutaneous mass in the parietal region, measuring 3×4 cm, and
there was no skin color change on the lesion. On brain magnetic resonance
imaging, an AVF was detected in the left parietal scalp with multiple feeding
arteries from the external carotid artery (ECA) and main venous drainage into
the left external jugular vein (EJV). Cerebral angiography confirmed a scalp AVF
with multiple arterial feeders of the occipital artery, middle meningeal artery,
superficial temporal artery, supraorbital artery, and vertebral artery on the
left side, draining mainly into the left superficial temporal vein (STV) and the
left EJV (Fig. 1A–F).

FIG. 1.

Cerebral angiography (A–F) shows a detailed angioarchitecture of the scalp
arteriovenous fistula (AVF) with feeding arteries from the left external carotid
artery, such as the occipital artery, middle meningeal artery, superficial
temporal artery, supraorbital artery (C, white arrow), and left vertebral artery
anastomosis (F, white arrow). The main venous drainage was the left superficial
temporal vein (STV) (A and D, black arrow). The roadmap image (G) shows balloon
occlusion in the distal STV. The scalp vascular lesion was filled with Onyx
casting during balloon occlusion (black arrow, H), and control angiography of
the left common carotid artery shows complete obliteration of the scalp AVF (I).



The treatment strategy was discussed by the neurovascular team, and endovascular
embolization was decided upon before surgery. Under general anesthesia, a
transvenous and transarterial approach was performed at the same time; a 5 Fr
Envoy guiding catheter (Cerenovus) was introduced into the left occipital
artery, and a 6 Fr Envoy guiding catheter was introduced into the distal STV via
the left EJV. Initially, the transarterial approach was attempted and failed
because the tortuosity of the feeding arteries prevented access with a
microcatheter to the distal fistulous point. Therefore, transvenous embolization
with a balloon was attempted due to the single venous route, which can control
outflow and deliver the embolic agent to the arterial bed during balloon
occlusion. After occlusion of the left STV with a Sceptor C balloon catheter
(4×10 mm, MicroVention), embolization was performed with 7.5 mL of Onyx-18
(Medtronics) through the same balloon catheter (Fig. 1G–I). Control angiography
showed complete obliteration of the scalp AVF, and the patient was discharged
without complications 2 days after embolization. At follow-up, no symptoms were
noted, including mass effect, inflammation, and discoloration.
Go to :



DISCUSSION

Scalp AVF is a rare vascular pathology with a heterogeneous angioarchitecture.
Sofela et al. [3] reported that scalp AVFs were spontaneous in 60%, traumatic in
32%, and iatrogenic in 8% of cases. AVF and pseudoaneurysm were the most common
manifestations, while AVF was even rarer. Scalp AVF was common in young females
with a median duration of 3 years, and the most common symptoms were a pulsatile
mass, headache, and tinnitus.
Surgical excision represents the initial treatment option for this vascular
lesion, which can be complicated by the potential for significant bleeding and
the possibility of scalp injury. As a result, endovascular therapy has been
widely used as an alternative or adjunct to open surgery. A variety of
endovascular techniques, including transarterial, transvenous, and direct
puncture, have been developed to occlude the arteriovenous shunt, and various
embolic materials such as coils, glues, and Onyx have also been used
[2,11,12,14-17]. In a systemic review of 243 cases of scalp AVF [3], more than
50% of cases were treated with surgical excision alone, 21.6% with endovascular
embolization alone, and 14.5% with hybrid methods. Complications were
significantly higher in the EVT group, which showed transient scalp pain and the
presence of residual mass after embolization, whereas scalp necrosis and wound
infection were most common in surgical treatment [3,19]. However, there is a low
recurrence rate after treatment regardless of the modality [3].
This complex vascular lesion was classified into 3 types by Yokouchi et al.
[18]: type A, a single fistula fed by a single proximal feeding artery; type B,
a single fistula fed by multiple arterial feeders; and type C, multiple fistulas
with plexiform feeding arteries and a main dilated draining vein. Our case was
type B, with multiple feeders from the ECA and draining mainly into the STV. In
scalp AVF, the transarterial approach can be challenging due to the severe
tortuosity of the feeders from the ECA. While distal access to the fistulous
point may be achievable, pulmonary embolism from liquid embolic agents should be
considered, given the characteristics of this scalp lesion with high-flow AVF.
In this case, the balloon catheter was accessible via the STV as the primary
venous route, and the liquid embolic agent could be safely injected during
occlusion of the venous outflow, allowing retrograde filling of the feeding
arteries. It was fortunate to achieve a successful embolization of the scalp AVF
in a single session, and the symptom was resolved immediately with no procedural
complications.
In this case, transvenous Onyx embolization was performed with the Sceptor C
balloon, which has a dual-channel design that allows both balloon occlusion and
Onyx injection within the balloon catheter. As a result, this embolization
procedure was very simple and took less than 1 hour. In a previous report,
transvenous embolization was performed using a single-channel Hyperform balloon
(Medtronic), and Onyx embolization required an additional microcatheter for Onyx
injection [17]. In addition, Onyx was chosen as the initial option because of
its ability to occlude the shunt from the venous outlet to the arterial feeders,
a process that may be facilitated by the non-adhesive properties of Onyx.
Go to :



CONCLUSION

In conclusion, this case demonstrates that transvenous embolization with balloon
occlusion is an effective treatment for complex scalp AVFs, especially when
transarterial approaches are challenging. The successful outcome without
complications highlights the importance of tailoring treatment strategies to the
specific vascular anatomy of each patient.
Go to :



NOTES

Fund

None.

Ethics Statement

Institutional Review Board approval is waived for the use of anonymized patient
data for retrospective clinical case report.

Conflicts of Interest

SHS has been the Editor-in-Chief of the Neurointervention since 2023; however,
SHS has not been involved in the peer reviewer selection, evaluation, or
decision process of this article. No potential conflict of interest relevant to
this article was reported. No other authors have any conflict of interest to
disclose.

Author Contributions

Concept and design: TK and SHS. Analysis and interpretation: TK. Data
collection: TK and SHS. Writing the article: TK. Critical revision of the
article: TK and SHS. Final approval of the article: SHS. Overall responsibility:
SHS.

Go to :






REFERENCES

1. Hu K, Zhang S, Liu J. Iatrogenic scalp arteriovenous fistula after
venipuncture. Neurol India 2024;72:453-454.


2. Alfaro AJQ, Ortíz AFH, Mejia JA, Ortegon JDC, Gutierrez LC, Tovar CAD, et al.
Traumatic scalp arteriovenous fistula post capillary implantation successfully
treated using PHIL embolic agent. Surg Neurol Int 2023;14:12


3. Sofela A, Osunronbi T, Hettige S. Scalp cirsoid aneurysms: case illustration
and systematic review of literature. Neurosurgery 2020;86:E98-E107.


4. Zheng F, Augustus Pitts H, Goldbrunner R, Krischek B. Traumatic arteriovenous
fistula of the scalp in the left temporoparietal region with intra- and
extracranial blood supply. Case Rep Vasc Med 2016;2016:8671472


5. Champeaux C, Jecko V, Penchet G, Chibbaro S. Scalp arteriovenous fistula
following hair transplantation. Clin Neuroradiol 2014;24:285-288.


6. Karampelas I, Cole PM, Kuensting JM, Fenstermaker RA. Diagnosis and
conservative management of an arteriovenous fistula of the scalp following awake
craniotomy for tumor resection. Acta Neurochir (Wien) 2007;149:727-728
discussion 728


7. Kim DM, Benndorf G, Von Moers A, Campi A, Lehmann TN. Spontaneous scalp
arteriovenous fistula in a child with hartnup disease. J Endovasc Ther
2004;11:348-350.


8. Tokunaga K, Kusaka N, Nakashima H, Ohmoto T. [A case of a scalp arteriovenous
fistula associated with Rendu-Osler-Weber disease treated by direct percutaneous
embolization]. No Shinkei Geka 2000;28:447-452 Japanese


9. Kuroki K, Taguchi H, Sumida M, Eguchi K, Saitoh Y. [A case of hemorrhagic non
traumatic arteriovenous fistula of the scalp]. No Shinkei Geka 1999;27:851-853
Japanese


10. Ordaz JD, Villelli NW, Bohsntedt BN, Ackerman LL. Delayed presentation of a
traumatic scalp arteriovenous fistula. Surg Neurol Int 2021;12:238


11. Walker GB, Wang AP, Hadwen J, Erdenebold UE, Bebedjian R, Sullivan P, et al.
Direct puncture of the superficial temporal artery in embolization of a scalp
arteriovenous fistula: a case report. Neurointervention 2023;18:67-71.


12. Subhan M, Shah S, Patel S, Ramanathan A. Hybrid endovascular and surgical
treatment of a traumatic scalp arteriovenous fistula. Cureus 2023;15:e49450.


13. Kojima D, Akamatsu Y, Fujimoto K, Oikawa K, Kashimura H, Kubo Y, et al.
Utility of manual venous compression during transvenous Onyx injection for a
scalp arteriovenous fistula: illustrative case. J Neurosurg Case Lessons
2022;4:CASE22317


14. Alawneh K, Al-Barbarawi M, Qawasmeh MA, Raffee LA, Al-Mistarehi AH.
Successful use of neurovascular plug for embolization of scalp arteriovenous
fistula: a novel technique. J Endovasc Ther 2022;29:827-834.


15. Kawano D, Fukuda K, Fukumoto H, Horio Y, Takahara M, Abe H, et al. The
usefulness of temporary balloon occlusion during transarterial embolization for
scalp arteriovenous fistula. Surg Neurol Int 2021;12:89


16. Dabus G, Pizzolato R, Lin E, Kreusch A, Linfante I. Endovascular treatment
for traumatic scalp arteriovenous fistulas: results with Onyx embolization. J
Neurointerv Surg 2014;6:405-408.


17. Dalyai RT, Schirmer CM, Malek AM. Transvenous balloon-protected embolization
of a scalp arteriovenous fistula using Onyx liquid embolic. Acta Neurochir
(Wien) 2011;153:1285-1290.


18. Yokouchi T, Iwabuchi S, Tomiyama A, Samejima H, Ogata N, Goto K.
Embolization of scalp AVF. Interv Neuroradiol 1999;5 Suppl 1:121-126.


19. Singla A, Fargen KM, Hoh B. Onyx extrusion through the scalp after
embolization of dural arteriovenous fistula. BMJ Case Rep
2015;2015:bcr2015011879


Go to :

Abstract
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
Notes
REFERENCES
TOOLS
 * PDF Links
 * PubReader
 * ePub Link
 * XML Download
 * Full text via DOI
 * Full text via PMC
   
 * Download Citation
 * Print

Share : METRICS
 * 0 Crossref
 *    
 * 428 View
 * 47 Download
 * 

Related articles in NI

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistula via Radial
Artery and Median Cubital Vein2021 July;16(2)

Angioarchitecture of Spinal Dural Arteriovenous Fistula - Evaluation with 3D
Rotational Angiography2012 February;7(1)

Vein of Galen Aneurysmal Malformation: Treatment by Transarterial Venous Sac and
Fistula Embolization Using Coils and Glue.2006 August;1(1)

Endovascular Treatment of Dural Sinus Malformation in Infant: A Case Report.2007
February;2(1)

Endovascular Treatment of Spinal Dural and Epidural Arteriovenous Fistula as
Complication of Lumbar Surgery.2007 August;2(2)

--------------------------------------------------------------------------------

--------------------------------------------------------------------------------

ABOUT
 * Aim and scope
 * About the journal
 * Editorial board
 * Best practice
 * Open access
 * Contact us

ARTICLE CATEGORY
 * Editorial
 * Review
 * Original Paper
 * Case Report
 * Letter to Editor

Browse all articles >

BROWSE ARTICLES
 * Current issue
 * All issues
 * Ahead-of print
 * Most viewed
 * Most download
 * Most cited
 * Funded articles
 * Neurointervention Search
 * Author index

AUTHOR INFORMATION
 * Instructions for authors
 * Research and publication ethics
 * E-submission
 * Author’s checklist
 * Copyright transfer agreement
 * Conflict of interest disclosure form

Editorial Office #705-2C, 9 Gangnam-ro, Giheung-gu, Yongin-si, Gyeonggi-do
16977, KOREA
Tel: +82-31-994-4382    Fax: +82-2-2275-9198    E-mail:
editor@neurointervention.org                

Copyright © 2024 by Korean Society of Interventional Neuroradiology.





Texte d'origine

Évaluez cette traduction
Votre avis nous aidera à améliorer Google Traduction