PMC9358026_01
The patient presented with a pulsatile forehead mass without specific medical history. Selective cerebral DSA confirmed the presence of scalp AVM. Angiographic images showed that the feeding arteries of the lesion were bilateral frontal branches of STAs and ophthalmic arteries (A). Onyx-18 liquid embolic material was injected to embolize the draining veins, fistulous connection, and feeding arteries. (B) Angiography was performed via microcatheter (i,ii); Penetration and solidification of Onyx after embolization (iii,iv); (C) Post-embolization angiography demonstrated the scalp AVM was occluded completely without non-targeted vessels embolization.
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F1
DSA confirmed the presence of frontal sAVM with feeding arteries from bilateral frontal branches of STAs and ophthalmic arteries and draining into orbital veins and facial veins (Figure 1A). The contrast was injected to confirm the position of the microcatheter tip within the draining vein and was close to the fistulous connection (Figures 1Bi,ii). Onyx-18 (ev3 Endovascular; Medtronic, Minneapolis, Minnesota, USA) liquid embolic material (2.5 ml) was then carefully injected through the microcatheter under a road map and allowed to diffuse to fill the draining veins, fistulous connection, and the feeders successfully (Figures 1Biii,iv). Post-embolization angiography of bilateral internal carotid arteries (ICA) and ECAs demonstrated complete sAVM occlusion immediately after Onyx-18 injection (Figure 1C).
(A,B) Direct percutaneous catheterization of the draining veins was performed with an 18-gauge needle.
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F2
In consideration of the location of the sAVM, access was obtained through direct puncture of the enlarged frontal vein with an 18-gauge needle and sutured in place (Figures 2A,B).
(A) The soft and pulsatile lesion with no clear border before treatment; (B) Immediate status of the lesion postembolization; (C) One-year follow-up showed no evidence of recurrence and scalp necrosis. Onyx was not visible beneath the skin; (D) Follow-up angiography showed complete occlusion of the scalp AVM.
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F3
The size of the mass decreased immediately after the embolization and did not present any more pulsation (Figures 3A,B). One-year follow-up cerebral angiography demonstrated no evidence of the sAVM recurrence (Figure 3D). No skin necrosis was observed (Figure 3C).
PMC9358026_02
(A) DSA showed right occipital high flow scalp AVM fed from the right OA branches and drained to the external jugular vein; (B) Onyx-18 was injected via direct percutaneous puncture approach (i,ii); Immediate complete occlusion of the scalp AVM post-embolization (iii,iv).
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F4
DSA was performed. DSA confirmed the diagnosis of high-flow right occipital sAVM and revealed arterial supply from right OA, whereas the temporal and occipital tributaries of the external jugular vein were acting as drainers (Figure 4A). Post-embolization angiography showed that the fistula was occluded and no non-targeted embolization (Figure 4B), with preservation of the main intracranial branches of bilateral ICAs.