Treatment of scalp arteriovenous malformation

We report seven patients with scalp arteriovenous malformations, including two patients with lesions > 10 cm in diameter, who were successfully treated. The principal complaint of each patient was a deforming mass. Each of four patients had a history of blunt traumatic injury. The lesions, each consisting of the nidus, feeders, and draining veins, evolved in all patients. The nidus consisted of fistulae, which exhibited various angioarchitectures as revealed by angiography. A hemangiomatous component was histologically recognized in one patient. In five patients, in whom the lesions were relatively small and whose nidi included only large fistulae, the malformations were remedied by surgical intervention alone or were cured with embolization alone using liquid adhesives. In the two patients with lesions > 10 cm, the nidi consisted of numerous large fistulae and plexiform fistulae in one patient and plexiform fistulae and a hemangiomatous component in the other patient. These patients were treated with a combination of transarterial embolization and surgical intervention. Preoperative embolization greatly reduced blood loss during resection. Total excision and scalp reconstruction using a soft tissue expander were performed in both patients. The cosmetic results were excellent in all of the patients, and no recurrence has been recognized during the follow-up period, which ranges from 31 to 99 months. The treatment of scalp arteriovenous malformations should strive to improve deforming features and to attain a permanent cure. Because each nidus includes a variety of anomalous angioarchitectural features, there should be different means and a combination of treatments for each patient. Embolization alone could be adequate treatment in relatively small lesions, the nidi of which consist only of several large fistulae. For malformations with more extensive, large fistulae or with anomalous components other than large fistulae, a combined endovascular and surgical approach and scalp reconstruction seems to be the best treatment.     

Neuro-interventional treatment of cerebrovascular malformations

Cerebral vascular malformations are relatively rare diseases, however, their clinical impact is high. The group of vascular malformations include arterio-venous malformations of the brain and of the dura mater (AVM and DAVM) and arterial aneurysms. The danger coming from these malformations lies in the ruture with following cerebral stroke. Patients may die directly, or suffer from numerous deficits as hemipegia, loss of vision or speech and several severe cognitive deficits. Early diagnosis and early treatment is most important to avoid such complications and to prevent the patients from permanent invalidisation. A therapeutic alternative with increasing impact is given with the minimal invasive endovascular procedures. Alone, or in combination used with Radiosurgery and Neurosurgery, these techniques enable a most optimal and risk-reduced therapy for the patients.     

Electron paramagnetic resonance studies of cobalt-substituted angiotensin I-converting enzyme

The traditional treatment of high-flow vascular malformations consists of selective embolization, surgical removal, or a combination of both. Recurrence of the lesion and bleeding control are still the main problems, and the result of treatment is sometimes disappointing. We suggest treatment of these lesions with surgical ligation of the distal major feeding arteries followed by intravascular injection of a sclerosing agent (3% tetradecyl sulfate), and surgical excision and reconstruction when indicated. We have found this to be an effective treatment regimen. We present 14 cases of high-flow vascular malformations of the head and neck area treated with this approach, of which 4 cases developed skin necrosis. Three of these 4 cases of skin necrosis were later treated with skin grafting and, in 1 case, an upper arm skin tube flap was used for nasal tip reconstruction. Three cases underwent delayed reconstruction using tissue expanders. From a symptomatic and aesthetic point of view, preliminary satisfactory results were obtained. We feel that this approach is a good option for treating difficult, high-flow vascular malformations.     

Hospital catchment areas and surgery in Meru district, Kenya

The surgical treatment of chronic epilepsies is increasing rapidly. A review of 279 surgical specimens of patients with chronic pharmaco-resistant epilepsies from the University of Bonn Medical Centre revealed specific histopathological findings in 89% of all well-preserved specimens. The most frequent focal lesions were low-grade brain tumours such as gangliogliomas, pilocytic astrocytomas and dysembryoplastic neuroepithelial tumours. Other common findings were glioneuronal and vascular malformations and Ammon's horn sclerosis. This suggests that chronic intractable epilepsies are frequently caused by structural alterations.     

Gastrointestinal manifestations of vascular anomalies in childhood: varied etiologies require multiple therapeutic modalities

BACKGROUND/PURPOSE: Vascular anomalies, including hemangiomas and vascular malformations afford complex diagnostic and therapeutic challenges when gastrointestinal (GI) manifestations are present. METHODS: Twenty-one patients evaluated or treated in our Vascular Anomalies Program from 1993 through 1997 were reviewed retrospectively with regard to presentation, treatment modalities, and outcome. RESULTS: Four patients had hemangiomas, and 17 had various vascular malformations. GI symptoms began in infancy or early childhood in all patients. Manifestations included GI bleeding (n = 15), obstruction (n = 2), diarrhea (n = 2), ascites (n = 2), pain (n = 1), emesis (n = 1), ileo-ileal intussusception (n = 1), protein-losing enteropathy (n = 1), and hypersplenism (n = 1). Four patients had proven portal hypertension. Fourteen had associated musculoskeletal or cutaneous lesions. Congestive heart failure, partial anomalous pulmonary venous return, pulmonary edema, and pleural or pericardial effusion occurred in one patient each. Bleeding was the most common symptom of both hemangiomas and malformations. Of four patients with hemangiomas, three were treated with corticosteroids or interferon. Endoscopic banding and embolization of an associated arterioportal hepatic shunt were each used in one patient. One patient died. The malformations were treated with resection (n = 8), endoscopic banding or sclerosis (n = 7), percutaneous or intraoperative sclerosis (n = 5), embolization or device interruption (n = 3), and portosystemic shunt (n = 2). GI symptoms were ameliorated in 12 patients with malformation, improved in two, unchanged in two, and one died after prolonged palliation. CONCLUSIONS: Vascular anomalies with gastrointestinal manifestations are heterogeneous in their presentation and type. Although bleeding is the most common symptom of both hemangiomas and vascular malformations, treatment differs. Pharmacological angiogenesis inhibition is the mainstay of hemangioma therapy. Resection, endoscopic or radiologic vascular obliteration, and portal decompression are important in treating vascular malformations. An individualized and interdisciplinary approach is often required to successfully diagnose and treat these complex lesions.     

Endovascular treatment of traumatic and iatrogenic intrarenal arterial lesions by microcoil embolization

Selective embolization is the best treatment for intrarenal arterial lesions due to trauma or percutaneous procedures with non-controlled or recurrent haematuria. Three male patients, aged 20-70 (mean 49 years), were recently treated in our institution by means of arterial embolization with microcoils. Two patients presented a pseudo-aneurysm and an arterio-venous fistula secondary to percutaneous nephrolithotomy and one patient presented an isolated pseudo-aneurysm due to trauma. In the 3 cases, haematuria (associated with retroperitoneal haemhorrage in one case) was not controlled and required repeated units of blood. Embolization allowed definitive treatment of these lesions. One of our patients with a solitary functional kidney presented rapidly increasing renal failure which completely resolved after arterial embolization. We think that microcoils are the embolic agents of choice to perform endovascular treatment in this indication.     

Treatment of resistant forms and recurrence of Hodgkin''s disease]

BACKGROUND: Vascular anomalies (hemangiomas and vascular malformations) are frequently located in the oral cavity. They can be treated by cool steel surgery, cryotherapy, laser therapy, embolization, and sclerosis. The choice of treatment should depend on the type of vascular anomaly, its site, the general condition of the patient, and the doctor's experience. OBJECTIVE: The objective of this article is to assess the usefulness, indications, and advantages of transfixion technique in the treatment of oral vascular lesions. METHODS: We present seven patients with various vascular anomalies in the oral cavity that were treated using transfixion technique. This procedure is performed with local infiltration anesthesia and it consists of interlacing a polyglycolic acid suture a number of times in an upward direction until the vascular anomaly becomes bloodless. RESULTS: In all seven patients we completely eliminated the vascular lesion without significant long-term complications. We detected a transitory retractil scar in only one patient and edema in the postoperative period in another one. CONCLUSIONS: Treatment of vascular anomalies of the oral cavity by transfixion technique is an effective, simple method that does not cause major complications and is low in cost.     

Large arteriovenous malformations of the face: aesthetic results with recurrence control

Large facial arteriovenous malformations are problematic for patients because of grotesque disfigurement, risk of rapid enlargement, and life-threatening rupture. Successful treatment of these relentless complex lesions is one of the most difficult challenges facing plastic surgeons. From a series of 300 large facial arteriovenous malformations, 85 patients were treated with embolization and excision; six of these cases (representing six separate anatomic regions: labial, auricular, eyelid, cheek, chin, and occipitoparietal) were selected for review. The purpose of this article was to look critically at the management of these six facial arteriovenous malformations, including patient presentation, angiographic procedures, surgical planning and technique, and postoperative long-term follow-up care. Lessons learned from the six representative cases provide clues for the management of large facial arteriovenous malformations and demonstrate the possibilities of recurrence and their occasionally relentless behavior. The cases show that long-term control of these lesions with acceptable aesthetic results can be achieved. The mainstay of treatment includes the following: (1) selective intra-arterial embolization with fine catheters and direct lesional embolization; (2) judicious resection and reconstruction with local or expanded tissue flaps; and (3) careful follow-up with serial examinations, duplex, and arteriography.     

Vascular malformations of the spinal cord. Diagnosis and therapy

A review is given on the current diagnosis and treatment of spinal vascular malformations with special emphasis on the use of selective spinal angiography. Spinal vascular malformations are mostly encountered within the thoraco-lumbar segment of the spinal cord. Typical clinical symptoms are due to either progressive myelopathy or hemorrhage (subarachnoidal hemorrhage). The prognosis of untreated spinal angiomas is poor. Therefore, therapeutic measures are aiming to prevent bleeding of angiomas resulting in subarachnoidal hemorrhages or hematomyelia or to prevent spinal cord ischemia due to compression. Using selective spinal angiography, spinal angiomas can now be treated successfully by complete surgical extirpation or embolization procedures. The evaluation of radicular myelopathies and subarachnoidal hemorrhages of unknown origin has also considerably benefited from this technique. It is concluded that early diagnosis of spinal vascular malformations is of crucial importance for good therapeutical results.     

Vascular "tumors" and the rules of their surgical management

After defining vascular tumors and malformations, formerly called angiomas, the authors adopt the classification of the International Society for the Study of vascular Anomalies. The various groups of malformations, after definition of the subject and the problems raised, are illustrated by a number of clinical cases and the rules of surgical management are discussed. Capillary malformations, formerly called portwine stains, can be treated by dye laser, but sometimes tissue and orthognathic reconstructive surgery in the presence of a skeletal malformation. Lymphatic malformations (lymphangiomas), optimally assessed by CT or MRI, can be treated by a variety of approaches: sclerotherapy, surgery. Venous malformations raise very different problems in the cervicocephalic region and on the limbs and trunk, but always require a multidisciplinary approach with, according to the site, size and repercussions, Ethibloc percutaneous sclerotherapy, embolization, surgery. Arteriovenous malformations require complete surgical treatment, usually preceded by embolization; reconstruction consists of local flaps or skin expansion in simple cases, and revascularized free flaps in difficult cases. If the malformation is cosmetically and functionally acceptable, the authors propose conservative management. The first-line treatment of haemangiomas is pharmacological (corticosteroids, interferon), but surgery may be indicated in two situations: early and late. There is a renewed interest in early surgery, subtended by several factors including cosmetic concerns and the development of new technologies, including the Cavitron. Late surgery retains its classical cosmetic and functional indications. Two key-words dominate the rules of therapeutic management of all types of vascular malformations: a multidisciplinary approach and modesty.     

Reflections on the management of cerebral arteriovenous malformations

BACKGROUND: The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience. METHODS: A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates. RESULTS: The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure. CONCLUSIONS: In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered "good risk" malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered "poor risk" malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.     

Super-selective arteriography and embolization in severe epistaxis

Super-selective arteriography technique is described. This examination enables the finest collaterals of the branches of the external carotid to be shown. Numerous anastomoses which explain the ineffectiveness of certain arterial ligatures used in epistaxis can be seen. Embolization has become an extremely common method for all facial malformations responsible for epistaxis and for O.-R.-L. tumours fed by the external carotid. Several cases are described which demonstrate that embolization in severe epistaxis is a speedy, elegant and permanent method.     

Endovascular occlusion with a new mechanical detachable coil

OBJECTIVE: Metallic coils have been used for vascular embolization for many years but controlled-release coils have only recently become commercially available. Most of these devices are microcoils that were manufactured primarily for the packing of intracerebral aneurysms; therefore, they lack radial force and are not ideal agents for the occlusion of high-flow lesions such as pulmonary arteriovenous malformations (PAVMs). The objective of this study was to review our experience with a new detachable coil based on the conventional Gianturco-Wallace coil. SUBJECTS AND METHODS: The new detachable coil was initially used for the treatment of varicocele in 20 patients. Subsequently, the coil was used in 48 patients during 90 procedures for the treatment of PAVMs. RESULTS: A total of 548 coils were used. Complete occlusion of the testicular vein was achieved in all patients with varicocele. Successful occlusion of the PAVM being treated was achieved in all patients, and no instances of recanalization were documented in any of the patients who returned for follow-up angiography. Forty-one coils had to be removed completely from the catheter before detachment because of inappropriate size or position. Eight coils failed to detach easily, and six of these had to be removed. Most of these device failures were associated with kinking of the screw thread mechanism between the coil and the delivery wire. CONCLUSION: The Jackson detachable coil allows safer, more accurate, and more distal embolization of PAVMs than is possible with nondetachable coils. Complications associated with its use have been few.     

Subarachnoid hemorrhage during arteriovenous malformation embolization as a result of vessel wall "sandblasting"

OBJECTIVE: Preoperative selective particulate embolization of arteriovenous malformations can make subsequent surgical resection of such lesions safer for the patient and easier for the surgeon. Nevertheless, embolization carries intrinsic risks, which include subarachnoid hemorrhage. We report two cases of subarachnoid hemorrhage during particulate embolization that we think was attributable to catheter positioning near a vessel curve and subsequent denudation of the vessel wall to the degree that hemorrhage was induced.     

Evaluation and treatment of head and neck venous vascular malformations

Congenital venous vascular malformations of the head and neck are low-flow, nonproliferative lesions that should be distinguished from hemangiomas. The characteristic history and clinical findings can establish the diagnosis. Direct percutaneous puncture and contrast injection at the time of treatment delineate the lesion and its drainage pattern. Treatment must be individualized according to lesion extent, patient tolerance and physician experience. Sclerotherapy with ethanol has proved to be a successful treatment modality for these lesions, as demonstrated in this study of 57 patients. Surgery is used for treatment of clinically significant residual disease. A multidisciplinary approach to evaluation and treatment is key to successful management.     

Dexamethasone stimulation of glutaminase expression in mesenteric lymph nodes

Cystic lymphatic malformations (CLM) are superficial vascular hemodynamically inactive malformations of the lymphatic compartment. We propose a new approach which uses a sclerosing agent as an alternative to surgical resection. In the past nine years we treated 70 patients with CLM. Fifty-five percent were younger than five years of age with a male preponderance and most (80%) of the CLM were located in the maxillofacial region. They usually presented with functional impairment from the mass effect; others had infections, bleeding, or inflammation. The CLM were injected under fluoroscopic control with a sclerosing agent, Ethibloc, which dries up the pockets and reduces the mass. On follow-up the results were good in 62%, unchanged in 5%, and continued progression in 20%. Fifteen percent underwent surgery failures (24%) occurred in mixed forms of cystic and cellular lymphangiomas. Complications were minors. Percutaneous embolization is useful for CLM, with minimal risk, absence of scar, and it avoids surgery. It should be the first line of treatment for these lesions.     

Cracking the auditory genetic code: nonsyndromic hereditary hearing impairment

Vascular anomalies of the head and neck are common lesions of childhood. The vascular anomalies can be divided into hemangiomas and vascular malformations. Each of these lesions has a characteristic imaging appearance. Correctly classifying the anomaly is essential in directing the treatment of these lesions.     

Neurological findings in the normal elderly: prevalence and relationships with memory performance

Portal hypertension is a result of chronic liver disease in the majority of cases. Rare, potentially curable causes of portal hypertension include vascular conditions such as hepatic or portal venous thrombosis and arterio-portal fistulas. We present the rare case of a spontaneous splenic arterio-venous fistula in a 40 year old multiparous woman. The young woman presented with massive diarrhea, ascites, abdominal pain, and an abdominal machinery type bruit and represents the second ever reported case with diarrhea as presenting symptom of splenic arterio-venous fistula. The diagnosis was confirmed by color Doppler ultrasound. Transfemoral aortography was performed to assess the possibility of catheter embolization. Surgical intervention was initially complicated by collateral arterial tributaries of the fistula and finally resulted in a dramatic recovery with persistent resolution of all symptoms. This case report demonstrates a curable form of portal hypertension that must be considered in acute onset portal hypertension in multiparous women and in the absence of liver disease. A machinery type bruit in the upper left abdominal quadrant represents an important and simple diagnostic symptom found by auscultation. Color Doppler ultrasound represents a non invasive, universally applicable and fast method of establishing the diagnosis. The literature and management of splenic arterio-venous fistulas are reviewed.     

Cranial axial computerized tomography in children (author's transl)

This report on computerized tomography in 400 children confirms the high diagnostic value of the new method in neuropediatrics. 31 brain tumours were diagnosed in children. Tumors present themselves as lesions of latered density compared to that of brain matter. Intravenous injection of contrast media increases the density of various lesions as tumors, angiomas, acute infarctions and abscess. Infarctions are low density lesions whereas hemorrhage is a high density lesion and both are thus safely differentiated. Edema may be visualized in the vicinity of tumours in brain injuries and in encephalitis. The normal ventricular system, hydrocephalus, cerebral malformations and subdural hygroma are easily demonstrated. Diseases of the orbits may also be detected.     

Transcatheter embolization of symptomatic hepatic venous malformations

The aim of this study was to evaluate our results in treatment and management of symptomatic hepatic venous malformations using transcatheter embolization therapy. From 1991 to 1997 five venous malformations were embolized in one man and four women ranging in age from 31 to 50 years. All patients presented nonspecific abdominal pain and were assessed in the general surgery unit. Percutaneous embolization was recommended. In all cases polyvinyl alcohol was used to embolize the afferent arterioles. Clinical and echographic control follow-up was carried out on an outpatient basis in our Vascular and Interventional Radiology Unit. Embolization was possible in all cases. No complications developed during the procedure, except in one case where the subject suffered a spasm of the hepatic artery. Mean follow-up time was 42 months (6-73 months). Four patients remained asymptomatic during the entire follow-up period, whereas one patient required reembolization. In our experience, transcatheter embolization of hepatic venous malformations is a noninvasive technique which requires few admissions and presents few complications. With further use, it could become the treatment of choice in symptomatic hepatic venous malformations as an alternative to surgery.