Surgical management of scalp arterio-venous malformation and scalp venous malformation: An experience of eleven cases
A 43-years-old male patient presented with right-sided pulsatile, progressively increasing fronto-parieto-temporal swelling measuring about 15 × 19 cm. He had headache and tinnitus. The swelling was diffusely serpentine. There was skin changes (ulceration and healed ulcerated areas). He had a history of surgery 5 years back in another institution. According to the patient, the lesion progressively increased in size after the operation. He also had recurrent attack of haemorrhage from the ulcerated area but none were of serious nature to cause shock and were controlled by pressure dressings. CT scan showed large soft tissue swelling [] and the bony windows showed multiple erosions and prominent vascular marking. Right-sided common carotid artery and ECA angiogram showed huge dilatation of branches (occipital artery, posterior auricular artery, superficial temporal artery and maxillary artery and its branches, including meningeal and middle temporal arteries) of ECA supplying the AVM. Left ECA angiogram showed enlargement and tortuousity of left occipital, posterior auricular and superficial temporal arteries supplying the AVM crossing the midline. Both internal carotid artery (ICA) angiograms showed prominent ophthalmic and supraorbital and supratrochlear arteries supplying the AVM. ACA, middle cerebral (MCA) and vertebro-basilar arterial systems were normal and intracranial venous drainage system seemed to be normal []. Right-sided ECA was ligated at the beginning of operation through a neck incision (During ligation, partial rupture of ECA occurred, which was immediately controlled). Then, AVM was excised completely with some part of skin (ulcerated and infected area). At the posterior part of AVM, there was some intracranial venous connection through bony erosion. There was also some significant pericranial component of AVM. Wound was closed with a transposition scalp flap. Postoperatively, there was minor wound infection that was controlled by regular dressing and antibiotic. Cosmetic appearance improved after 2 months []. The patient has remained free of recurrence of AVM for last 1.5 years (until the last follow-up).