Traumatic Arteriovenous Fistula of the Scalp: Preoperative Embolization and Surgical Excision

Abstract

A 41-year-old woman, otherwise healthy, had sustained blunt trauma to her left temporal region 4 years earlier. She observed a local swelling of the left temporal region with circumscribed pain. Pulsatile tinnitus occurred 2 months after the trauma. Surgical ligation of the left superficial temporal artery was carried out in another hospital in the same year without improvement of either the swelling or the bruit. In the following 4 years, both bruit and temporal swelling gradually increased. She then presented to the referring hospital. MRI/MRA showed an enlarged vessel of the left temporal region. DSA revealed an arteriovenous shunt, mainly between the superficial temporal arteries of both sides and, to a lesser extent, of the other scalp arteries not supplied by pial arteries. The drainage was through the enlarged left superficial temporal vein. This vein was directly punctured under general anesthesia. The venous outflow was obstructed with detachable platinum coils. The varix was obliterated with nBCA glue (Glubran2, GEM) and ethiodized oil (Lipiodol, Guerbet). This procedure resulted in an angiographically confirmed interruption of the arteriovenous shunt. In order to prevent a possible recurrence of the arteriovenous fistula and for a better cosmetic result, the varix was subsequently surgically excised. The following course was unobtrusive, with primary wound healing. A follow-up DSA 2 weeks after the operation showed a normalization of the scalp vasculature without an arteriovenous shunt. The management of traumatic arteriovenous fistulae of the scalp is the main topic of this chapter.