Algorithmic Approach to Overcome Scalp Deficiency in the Setting of Secondary Cranial Reconstruction.

BACKGROUND: Multidisciplinary approaches have shown improved outcomes in secondary cranial reconstruction, however, scalp deficiency remains a common obstacle for tension-free scalp closure during cranioplasty. Therefore, our objective was to create an algorithmic approach using a novel concept of "component separation" to help minimize potential complications. METHODS: The authors tested the hypothesis of achieving greater scalp mobility by way of "component separation" in a half-scalp, bilateral cadaver study, and describe within 2 clinical examples. Pterional-sized (N = 2) and hemicraniectomy-sized (N = 2) scalp flaps were dissected on 2 cadaveric heads using an internal control for each scenario. All flaps (N = 4) were created with (experimental group) and without (control group) "retaining ligament release." Total amounts of scalp mobility were measured bilaterally and compared accordingly. RESULTS: Scalp flap mobility was calculated from the sagittal midline using identical arcs of rotation. With zero tension, we observed an increased distance of movement equaling 1 cm for the "experimental" pterional flap, compared with the contralateral "control." Similarly, we found an increase of additional 2 cm in scalp mobility for the "experimental" hemicraniectomy-sized flap. CONCLUSIONS: Tension free scalp closure is most critical for achieving improved outcomes in secondary cranial reconstruction. In this study, we show that a range of 1 to 2 additional centimeters may be gained through a component separation, which is of critical value during scalp closure following cranioplasty. Therefore, based on our high volume cranioplasty experience and cadaver study presented, we offer some new insight on methods to overcome scalp deficiency accompanying secondary cranial reconstruction.

Transvenous balloon-protected embolization of a scalp arteriovenous fistula using Onyx liquid embolic.

BACKGROUND: Scalp arteriovenous fistulas (AVFs) are rare and potentially complex lesions that can be treated in a multimodal fashion. We present here the first successful treatment of a Stage Ib scalp AVF using a balloon-protected, retrograde transvenous embolization with the liquid embolic Onyx. METHOD: We describe the case of a 60-year-old man with a scalp AVF that had a fine, diffuse, serpiginous arterial supply, precluding a transarterial approach, and multiple venous drainage paths, including the external jugular vein (EJV). The lesion was successfully embolized exclusively via a femoral transvenous retrograde approach using Onyx with balloon-protection of the EJV to simultaneously prevent pulmonary embolism and enable improved retrograde casting of the fistula-outflow zone. FINDINGS: The combined use of Onyx with proximal balloon-protection in a transvenous retrograde femoral approach is a novel method that can be used to definitively treat scalp AVFs with a defined catheter-accessible venous outflow. CONCLUSION: This technique may be useful when transarterial embolization, direct puncture, or surgical excision are not practical or possible.

Pre-Surgical Endovascular Proximal Feeder Artery Devascularization Technique for the Treatment of Cranial Arteriovenous Malformations.

OBJECTIVE: Treatment of brain arteriovenous malformations (AVMs) aims to abolish any risk for intracranial hemorrhage with the preservation of the patient's functional status. We present the technique of pre-surgical endovascular devascularization through proximal feeder artery occlusion for the treatment of cranial AVMs rather than nidus occlusion. Also, we highlight the advantages and the possible clinical indications. PATIENTS AND METHODS: Two patients with brain AVM and one patient with scalp AVM were treated by pre-surgical endovascular devascularization followed by surgical resection. Endovascular devascularization was performed by occlusion of the AVM feeders only with Liquid Embolic System Agent (Onyx®) 18 without entering and filling the nidus. During surgery, feeding arteries colored with the black color of the Liquid Embolic System Agent were clearly identified and cut. Dissection of the AVM was performed, and resection of the nidus was achieved. RESULTS: Total resection of the AVM was achieved in all cases confirmed with follow-up angiographies, with no neurologic or systemic complications. Also, no major bleeding was detected. In addition, the surgical clips were avoided during surgery. Brain AVMs were safely resected in piecemeal fashion. CONCLUSION: Pre-surgical endovascular proximal feeder artery devascularization technique shows to be a safe, simple and effective technique for the management of cranial arteriovenous malformations. This technique simplifies both the endovascular and surgical approaches to complicated cranial AVM cases.

Endovascular treatment of scalp cirsoid aneurysms.

BACKGROUND: Scalp is the most common site of soft tissue arteriovenous fistulae and surgical excision has been the primary mode of treatment. Endovascular treatment has evolved as an alternative to the surgery. AIMS: To evaluate the effectiveness of percutaneous direct-puncture embolization of cirsoid aneurysms. MATERIALS AND METHODS: From January 1995 to December 2004, 15 patients underwent percutaneous direct-puncture embolization of cirsoid aneurysms. Plain X-ray, computerized tomography scan and complete selective cerebral angiogram were done in all. Seven patients had forehead lesions, four had temporal and the remaining four patients had occipital region cirsoid aneurysms. Lesions were punctured with 21-gauge needle and embolized with 20-50% cyanoacrylate-lipiodol mixture. Circumferential compression was applied during injection. RESULTS: Post-embolization angiogram showed complete obliteration in 11 patients. The remaining four patients required adjunctive transarterial embolization with polyvinyl alcohol particles for complete lesion devascularization. Two patients had post procedure surgery for removal of disfiguring and hard glue cast. There were no major procedure-related complications. No patients had any recurrence in the follow-up. CONCLUSION: Percutaneous direct puncture embolization of cirsoid aneurysms is a safe and effective procedure. It can be effectively used as an alternative to surgery. Sometimes adjunctive transarterial embolization is also required to deal with deeper feeders.

Percutaneous direct puncture glue embolization of high-flow craniofacial arteriovenous lesions: a new circular ring compression device with a beveled edge.

SUMMARY: The purpose of this study was to evaluate the efficacy of a newly designed circular ring compression device that allows safe and effective glue injection during preoperative embolization of high-flow superficial craniofacial arteriovenous malformations (AVMs). The device was used in 4 cases of craniofacial AVM with multiple feeding arteries and draining veins. It provided a safe glue injection route as well as effective compression of radiating multiple venous drainage routes.

Transvenous Endovascular Treatment for Scalp Arteriovenous Fistulas: Results with Combined Use of Onyx and Coils.

BACKGROUND: Scalp arteriovenous fistulas (AVFs) are rare lesions that may occur spontaneously or secondary to head trauma. A standard treatment strategy for these lesions has not been established to date. We present 3 cases of successful treatment of scalp AVFs using a combination of Onyx-18 and coils via a transvenous approach. METHODS: The patient database at Huashan Hospital, Fudan University, Shanghai, China was reviewed, and patients with scalp AVFs treated with Onyx-18 and coils via a transvenous approach were identified for analysis. RESULTS: Between 2014 and 2016, 3 consecutive patients with scalp AVFs were treated transvenously with Onyx embolization in combination with coil placement at our hospital. No procedure-related complications were noted. Postembolization angiography demonstrated successful and complete occlusion of the AVFs immediately after treatment. Clinical follow-up showed resolution of symptoms. CONCLUSIONS: The technique of transvenous "armored concrete" embolization using a combination of coils and Onyx is an effective treatment modality for scalp AVFs, particularly in type C cases.

The application of hair-bearing flaps in head and neck surgery.

The history of hair-bearing flaps is presented. A study of the vascular supply of the scalp with a particular emphasis on the posterior branch of the superficial temporal artery revealed that it was possible to transpose the entire scalp or any hair-bearing flap on a long, highly mobile, narrow pedicle containing this vessel. Clinical application of this finding to postexcisional defects allowed the reconstruction of hairline, eyebrows, sideburns, and various shapes of beards and moustaches. The technique was used on 80 occasions to produce various cosmetic units and proved to be a safe procedure.

Ischemic necrosis of the scalp after preoperative embolization of meningeal tumors.

The authors report two patients who suffered ischemic necrosis of their scalps after preoperative therapeutic embolic occlusion of the external carotid artery and its terminal branches for highly vascular meningeal tumors. Local anesthesia, selective catheterization of the external carotid artery, and radiopaque polyvinyl alcohol and Gelfoam as embolic agents were used. The various complications of external carotid artery embolization are reviewed. The importance of preserving normal branches of the external carotid artery (especially the superficial temporal artery) during embolization and of careful design of the scalp flap to avoid ischemic necrosis is emphasized.

[Super-selective cerebral angiography. III. Diagnostic use and therapeutic possibilities of the telescopic catheterization technic in the circulation area of the external carotid artery in man]. / Superselektive zerebrale Angiographie. III. Diagnostische Anwendung und therapeutische Möglichkeiten der Teleskop-Kathetertechnik im Versorgungsbereich der A. carotis externa des Menschen

The diagnostic value and technical versatility of the previously described telescopic catheter system was demonstrated in 15 patients by super-selective angiography of the external carotid artery. It was possible in all patients to catheterise the individual branches with the F-catheter; the polyethylene-S-catheter could then be passed 3 to 5 cm, beyond the tip of the F-catheter. In almost half the patients, spasm of the injected artery was observed, particularly of the superficial temporal and external occipital arteries; this was reversed by intravenous papaverine and did not interfere with detailed diagnosis. It was usually possible to obtain filling of peripheral vessels, thereby demonstrating the territory of the middle meningeal artery, the scalp, sub-mandibular gland and the pinna. There were no complications as a result of the catheterisation. The usefulness and advantages of the telescopic catheter system for therapeutic neuro-radiological procedures, with embolisation of external branches in man, are discussed.

Vascular anatomy of the galeal occipitalis flap: a cadaver study.

The vascular anatomy of the galeal occipitalis flap was studied in 10 fresh cadavers by an intraarterial dye injection technique. The scalp flap was based posteriorly, incorporating both the occipital and posterior auricular arteries. A good transmidline anastomosis was demonstrated between the two occipital arteries in the full-thickness scalp flap. However, in the isolated galeal flap, although the axial distribution of the occipital artery was maintained, fewer transmidline connections were seen between the two occipital arteries. The posterior auricular artery was consistently visualized in all dissections, and it showed good connections with the ipsilateral occipital artery. However, there were very few anastomoses between the two posterior auricular arteries across the midline. The rich anastomotic network between the occipital artery and the posterior auricular artery extended well beyond the vertex. This study showed that a large flap can be raised if both the occipital artery and the posterior auricular artery are included in its base. The occipital artery is a vessel of satisfactory size and is potentially a good vascular source for a thin galeal free flap. It is recommended that the flap be raised at the subperiosteal level for ease of dissection and protection of the vessels, which are initially in the subgaleal plane and then arborize in the galea.

The vascular anatomy of the galeal flap in the interparietal and midline regions.

The potential extension of the galeal flap in the interparietal area was studied on 17 fresh human cadaver heads by intravascular dye injection technique. It was demonstrated that an ipsilateral superficial temporal artery that supplies the galeal flap does not cross the midline or anastomose with the contralateral superficial temporal artery but ensures the survival of a flap extended up to 1 cm proximal to the sagittal suture line. The width of the temporoparietal flap can be extended up to 15 cm, depending on the vascular pattern of the superficial temporal artery. When required, the lateral extension may provide the required soft-tissue bulk despite the reduced flap length.

Non-traumatic arteriovenous fistulas of the scalp treated by a combination of embolization and surgical removal.

Three patients with non-traumatic arteriovenous fistulas (AVFs) of the scalp were treated by embolization using acrylate glue through the transarterial route or by direct puncture of the lesions and then surgical resection. Complete cure was achieved in all three patients. Selective angiography is indispensable in the correct diagnosis of scalp AVFs. Embolization facilitates surgical removal when necessary, and this combination is the treatment of choice for scalp AVFs.

[GAPO syndrome]. / Le syndrome GAPO.

INTRODUCTION: The GAPO syndrome is a rare but distinct genetic disorder. GAPO is an acronym for the manifestation of Growth retardation, Alopecia, Pseudoanodontia and Optic atrophy. The syndrome was first reported in 1947; to date, 24 cases have been reported. We report the first Tunisian case. OBSERVATION: We studied a 12 year-old boy with GAPO syndrome which was associated with peculiar facial appearance, umbilical hernia, hemangiomatous plaques of the neck, depigmented maculae arranged in a splashed pattern located in the trunk and the right upper limb. He had a pulsated mass in the right mastoid area and a bruit was audible, he had a second flaccid mass of the vertex. These tumefactions correspond to very developed commissure veins. DISCUSSION: In addition to the classical manifestations of the GAPO syndrome, the patients have a strikingly characteristic facial appearance and may also have umbilical hernia, skin redundance and prominent dilatation of scalp veins. Our case had depigmented maculae suggestive of incontinentia pigmenti achromians. This has never been reported previously. The pathogenesis of this syndrome is unknown and inheritance is considered to be autosomal recessive.

[Artificial embolization with cyanoacrylate for the treatment of the extracranial arteriovenous malformation].

Two cases of the extracranial arteriovenous malformation (AVM) were treated by intra-arterial injection of cyanoacrylate (Aron alpha A). The first case was a 31-year-old man who had an AVM in the left temporal muscle. At operation, the feeders, the left anterior and posterior deep temporal arteries, were exposed and Aron alpha A was injected into these feeders. The pulsation of the AVM disappeared and the AVM became a hard mass. The mass was totally removed with remarkably little amount of bleeding. No complication was noted. The second case was a 23-year-old man who had an AVM in the scalp, and its feeder was the left occipital artery. The treatment was done in the same manner as in the first case. After operation the regional scalp became necrotic, but the epithelialization was completed in 3 weeks. No signs of recurrence of AVM were noted 20th and 21th month after operation in each of the cases. The recent literature were briefly reviewed.

Endovascular treatment for traumatic scalp arteriovenous fistulas: results with Onyx embolization.

BACKGROUND: Arteriovenous fistulas of the scalp (S-AVFs) are rare lesions and may occur spontaneously or secondary to trauma. The use of Onyx for the treatment of S-AVFs is not well established at this time. We discuss three cases of traumatic S-AVFs treated successfully with Onyx embolization alone or in association with coils. METHODS: The database of patients treated at the Baptist Cardiac and Vascular Institute, Miami, Florida, was reviewed. All patients with traumatic S-AVFs treated with Onyx were included. RESULTS: Two men and one woman with progressive enlarging pulsatile mass with bruit or tinnitus had angiographic evidence of S-AVF and were treated. In two patients the S-AVFs were secondary to hair transplantation. They were treated with Onyx-18 embolization as the single treatment modality. One patient with S-AVF resulting from temporomandibular joint arthroscopy was treated with coils and subsequent Onyx-34 embolization. In one patient, transarterial microcatheterization and injection of Onyx-18 was performed. In another patient, the intra-arterial approach was prevented by arterial vessel tortuosity. Therefore, access to the fistula was obtained through direct puncture of a large frontal vein; contrast injection confirmed the positioning of the needle within the draining vein of the AVF and Onyx-18 was then injected while the outflow vein was compressed. In the third patient in this series, coils were deployed to allow safer and more controlled injection of Onyx-34. No procedure related complications were noted. Post-embolization angiography demonstrated successful and complete occlusion of the AVF immediately after treatment. Follow-up revealed complete resolution of the symptoms. CONCLUSIONS: Our experience in this small series indicates that endovascular treatment of S-AVFs with Onyx is rapid, safe, and highly effective.

Cirsoid aneurysm of the right pre-auricular region: an unusual cause of tinnitus managed by endovascular glue embolisation.

OBJECTIVE: We report an interesting case of a right temporal pre-auricular arteriovenous fistula (cirsoid aneurysm) causing intractable tinnitus successfully managed by transarterial n-butyl cyanoacrylate glue embolisation. CASE REPORT: A 52-year-old female presented with a one-year history of tinnitus and pulsatile swelling in the right pre-auricular region. A colour Doppler ultrasound test and magnetic resonance angiography revealed a high-flow scalp arteriovenous fistula with a feeder vessel from the distal superficial temporal artery, which drained into the corresponding, dilated, tortuous vein. The patient underwent diagnostic digital subtraction angiography. This was followed by transarterial embolisation of the fistula using a 50 per cent mixture of n-butyl cyanoacrylate glue and Lipiodol®, with manual distal venous occlusion. A successful outcome was achieved with instant relief of symptoms. CONCLUSION: Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding.