Interventional Neuroradiology 5 (SuppI1), 1999
Embolization of Scalp AVF
T. YOKOUCHI, s. IWABUCHI,A. TOMIYAMA, H. SAMEJIMA, N. OGATA*, K. GOTO*
The Second Department of Neurosurgery; Toho University
* Department of Interventional Neuroradiology; Iizuka Hospital
Key words: arteriovenous fistula, embolization, scalp
Summary
We report scalp arteriovenous fistulas (AVFs) in
which we performed embolization and examine the
treatment method. The subjects were four cases of
scalp AVF treated by embolization. All cases were
male and three had a past history of scalp injury. As
the feeding artery, we found a single artery in one case
and multiple arteries in three cases. In three cases we
employed a transarterial approach by cutting down
the scalp and embolized the fistula with NBCA (N-
butyl-cyanoacrylate).
We conducted the embolization procedure as fol-
lows in order to securely occlude the fistula; 1) we ob-
tained the precise location of fistula by the superse-
lective angiography; 2) we induced the tip of micro-
catheter to immediately in front of fistula; 3) when
high flow shunt was manifested, we controlled the
flow by retaining the balloon catheter in the external
carotid artery; 4) and injected NBCA by compressing
around the fistula from above the scalp with a cylin-
drical instrument to prevent the migration of embolic
material to the venous side.
As a result, all cases were completely cured and
there was no major complication except for transient
postoperative pain. If the transfemoral approach to
fistula is impossible, it is considered effective to cut
down near the fistula and embolize the scalp AVF by
direct puncture to the feeding artery with NBCA as
embolic material.
Introdnction
Scalp AVF are found in a pulsating mass of the
scalp in many cases and progressively increase in
size. Therefore, from a cosmetic standpoint, scalp
AVF is considered as one of the diseases causing
anxiety to patients. It can even cause scalp necrosis
and bleeding. It is difficult to treat AVFs in the scalp
because incomplete obliteration of the fistula has
nearly always been followed by recurrence'.
On the other hand, scalp AVF can be healed by
embolization if the fistula can be occluded com-
pletely. We report the four cases of scalp AVF we
have experienced and examine the treatment
method.
Material and Methods
All four cases were male. Three cases had regions
on the right side and one had on the left side: three
were in temporal and one was in parietal region. As
the feeder, we found single artery in one case and
multiple arteries in three cases. Superficial temporal
artery (STA) was found in all cases and, in addition,
deep temporal artery (DTA), occipital artery (OA),
or posterior auricular artery (PAA) were found in
each case. Three cases had past history of injury: one
case (case 2) had complication of traumatic CCF on
~h~ opposite side, and one case having no history of
Injury (case 4) had complication of aneurysm in the
internal carotid artery of the same side.
We performed superselective angiography to all
cases through the transfemoral approach and con-
firmed the feeding arteries, draining veins, and fis-
tulae. We approached the fistula superselectively
with a microcatheter. However in three cases in
which the approach to fistula was difficult, we' di-
rectly punctured the feeding artery by cutting the
scalp down near the fistula. In order to prevent the
complication of scalp necrosis, we induced the mi-
crocatheter tip to immediately in front of the fistula
in all cases. If the AVF manifested a high flow shunt,
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Embolization of Scalp AVF
we controlled the flow by retammg a balloon
catheter in the external carotid artery and also in-
jected NBCA while compressing around the fistula
with a cylindrical instrument (figure 4) from above
the scalp to prevent the migration of embolic mate-
rial to the venous side.
Results
In the three cases to which we performed the em-
bolization with NBCA by directly puncturing the
feeding artery, slight shunt flow remained immedi-
ately after the embolization. However in the follow-
up angiography at one week after, the A-V shunt dis-
appeared completely. Except for transient scalp
pain, there was no complication of scalp necrosis,
and the residual subcutaneous tumor caused by
thrombus disappeared in one to three months. All
cases were completely cured without complication.
Illustrative cases
Case 2
A 58-year-old man had the complication of right
scalp AVF and left traumatic CCF. Angiography
demonstrated that the CCF was a hazardous type re-
fluxing to the cortical vein, which we treated by the
embolization with five detachable balloons (figures
lA and lE). The scalp AVF was fed by the STA, and
an ascending drainer was observed from the STA-
STY shunt. In addition, the draining vein towards
the anterior portion was flowing into the superior or-
bital vein (SOV) (figures IC and ID).
Thus this is a case in which the migration of em-
bolic material must be carefully watched when per-
forming the embolization 3. We treated this case com-
pletely by directly puncturing the STA through cut-
ting down, and injection of NBCA while com-
pressing the scalp with a cylindrical instrument (fig-
ures lE and IF).
Table I Summary
Case Age Sex Location Fistula Feeder
1 58 M rt-temporal single STA,DTA
2 38 M rt-parietal single STA
3 43 M It-temporal single STA,PAA
OA,DTA
4 26 M rt-temporal single PAA, STA spontaneous
OA
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T Yokouchi
Case 4
This 26-year-old man presented with the compli-
cation of right scalp AVF and right internal carotid
aneurysm (figures 2A, 2B and 2C). The scalp pul-
satile swelling was located where the frame of the
glasses the patient was using touched. Thus the slight
stimulation to that region can be considered to have
caused the scalp AVF (figure 3). Furthermore, in the
extracranial segment of right internal carotid an-
giogram, irregular dilatation and stenosis like a
string of beans was shown in addition to the
aneurysm. Thus the possibility that the scalp AVF
might have been caused by some vascular disease
was suggested. The PAA was the main feeder to the
scalp AVF, and the STA and OA were also feeders
and accompanied by a venous varix (figure 2D). This
case was cured by the direct puncturing of the STA
through cutting down and controlling the flow of ex-
ternal carotid artery with a balloon catheter and em-
bolization while compressing the scalp with a cylin-
drical instrument (figure 2E).
Discussion
The occurrence frequency of extracranial AVM is
considered approximately one twentieth of that of
intracranial AVM, making the extracranial AVM as
a relatively rare disease 2. The diagnosis of AVF
Figure 1 Case 2. A, B) Right internal carotid angiogram. A)
(lateral view) The CCF is shown. B) (anteroposterior view)
Disappearance of the CCF after embolization with balloons.
C) Left external angiogram, lateral view, shows the scalp
AVF. The draining vein towards the anterior portion is
flowing into the SOY (arrow). D) Superselective angiog-
raphy of the left STA reveals a STA-STV shunt. E) Em-
bolization by direct puncture of the left STA with NBCA. F)
Left external carotid angiogram after embolization shows
disappearance of the AVF.
'\
Etiology Treatment Outcome Other
(Embolic material) finding
traumatic femoral transarterial emboli. cure
and excision (NBCA)
traumatic transarterial emboli. cure It-CCF
by direct punc. (NB CA)
traumatic transarterial emboli. cure
by direct punc. (NB CA)
transarterial emboli. cure rt-lC aneurysm
by direct punc. (NBCA) FMD?
 Interventional Neuroradiology 5 (Suppl1), 1999

123
Embolization of Scalp AVF T. Yokouchi

A B c

D E

F G

124
 Interventional Neuroradiology 5 (Suppl1), 1999

Figure 3 Photograph of case 4, Scalp mass in the right retroauricular re- Figure 4 Photograph of a cylindrical instrument
gion before treatment. for compressing above the skin around the fistula.

should be based on the feeding arteries, draining veins, sites

Figure 2 Case 4. A) Right internal carotid an-
giogram shows a large fusiform aneurysm and irreg-
ular wall of the extracranial segment. B, C) Right ex-
ternal carotid angiogram shows the AVF that fed by
the STA, the PAA and the OA. D) Angiogram ob-
tained during direct puncture of the STA close to the
fistula; E) embolization with NBCA. F,G) Right ex-
ternal carotid angiogram after embolization shows
disappearance of the AVF.
and number of the fistulas, their relationship to the adja-
cent normal vessels,and the amount of shunted flow 3. Re-
cently endvascular treatment has been considered the first
choice, as the definitive or presurgical treatment method of
these disease. In the cases of scalp AVF, not a little cases
could be completely cured only by embolization 1,4,5 .6,7.
For the cases having relatively high flow AVF fed from
the proximal artery such as Type A in figure 5, a transarte-

CLASSIFICATION OF SCALP AVM

A B C
single fistula single fistula multiple fistulas (AVM)
proximal feeding type multiple distal feeding type plexiform feeding type

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Vy)
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125
Embolization of Scalp AVF
rial approach is considered appropriate. In the cases
having many small feeders such as Type B, transve-
nous approach is considered appropriate. For the
cases having plexiform feeding and multi-fistula, the
so-called AVM (cirsoid aneurysm) type as shown in
Type C, a treatment method combining embolization
and surgical treatment is considered necessary 3.8.
This type of case must be cured completely because
the lisk of re-growth of the size of residual AVF is
very high 9 . It is, however, often difficult to cure scalp
AVFs with vascular connection of the pericranial
component 10.
As the points to be noted for the embolization of
scalp AVF, the fistula must be securely confirmed by
the superselective angiography to prevent the com-
plication of skin necrosis or the recurrence due to
the incomplete occlusion, and the catheter must be
inserted as closely as possible to the fistula so that
the fistula itself can be occluded. The migration of
embolic material via extracranial or intracranial
meningeal anastomosis or venous anastomosis may
cause unpredictable complication
Thus the dynamics of blood flow must be under-
stood angiographically as well as anatomically and a
sufficient flow control must be secured at arterial
References
1 Barnwell SL, Halbach VV et AI: Endovascular treatment
of scalp arteriovenous fistulas associated with a large
varix. Radiology 173: 533-539, 1989.
2 Olivecrona H, Ladenheim J: Congenital arteriovenous
aneurysms of the carotid and vertebral arterial system.
vol 1, Springer-Verlag, Berlin, Gottingen, Heidelberg
1957: 28.
3 Komiyama M, Nishikawa M et AI: Non-traumatic arteri-
ovenous fistulas of the scalp treated by a combination of
embolization and surgical removal. Neuro Med Chir
(Tokyo) 36: 162-165, 1996.
4 Heilman CB, Kwan ES et AI: Elimination of a cirsoid
aneurysm of the scalp by direct percutanous emboliza-
tion with thrombogenic coils. Case report. J Neurosurg
44: 753-756, 1976.
5 Kasdon DL, Altemus LR et AI: Embolization of a trau-
matic arteriovenous fistula of the scalp with radiopaque
Gelfoam pledgets. Case report and technical note. J Neu-
rosurg 44: 753-756, 1976.
6 Mourao GS, Hodes JE et AI: Curative treatment of scalp
arteriovenous fistulas by direct puncture and emboliza-
tion with absolute alcohol. Report of three cases. J Neu-
rosurg 75: 634-637, 1991.
7 Yoshimura S, Kaku Yet AI: Embolization of scalp AVF
by direct puncture of venous pouch. In: Taki W, Picard L,
Kikuchi H (eds): Advances in interventional neuroradi-
ology and intravascular neurosurgery. Elsevier, Ams-
terdam: 1996: 121-123.
126
T Yokouchi
and venous sides as necessary. Since the scalp ar-
teries meander, the transfemoral approach may not
be able to access to the fistula. In such a case with
tortuous feeder, it is considered effective to canulate
to feeding artery by direct percutaneous puncture
close to the fistula and use NBCA as the embolic
material. Even if a slight A-V shunt remains after
embolization, if the flow is delayed, thrombose can
be expected to occur progressively when NBCA is
used.
In addition, the residual thrombolic varix treated
with NBCA can be expected to disappear naturally
different from with the coils.
Conclusions
We have reported four cases of scalp AVF we
treated and discussed the treatment. In the cases of
scalp AVF, embolization must be considered as the
first choice treatment and canulation to the feeding
artery by direct percutanous puncture is effective.
However, in order to prevent complications, it is
important to understand the vascular anatomy and
dynamics of blood flow and securely occlude the
fistula.
8 Nagasaka S, Fukushima T et AI: Treatment of scalp ar-
teriovenous malformation. Neurosurgery 38: 671-677,
1996.
9 Khodadad G: Arteriovenous malformations of the
scalp. Ann Surg 177: 79-85, 1973.
10 Fisher-Jeffes ND, Domingo Z et AI: Arteriovenous mal-
formations of the scalp. Neurosurgery 36: 656-660, 1995.
Tetsuya Yokouchi, M.D.
The Second Department of Neurosurgery
Toho University