Update: Propionibacterium acnes

Propionibacterium acnes is the relatively slow-growing, typically aerotolerant anaerobic, Gram positive bacteria linked to the skin condition of acne; it can also cause chronic blepharitis and endophthalmitis, the latter particularly following intraocular surgery. The genome of the bacterium has been sequenced and a study has shown several genes can generate enzymes for degrading skin and proteins that may be immunogenic (activating the immune system).

This bacterium is largely commensal and part of the skin flora present on most healthy adult humans’ skin.

It is usually just barely detectable on the skin of healthy preadolescents. It lives primarily on, among other things, fatty acids in sebum secreted by sebaceous glands in the follicles. It may also be found throughout the gastrointestinal tract in humans and many other animals.

It is named after its ability to generate propionic acid.


Propionibacterium acnes was cultured from intervertebral disc tissue of ~25% of patients undergoing microdiscectomy, suggesting a possible link between chronic bacterial infection and disc degeneration. However, given the prominence of P. acnes as a skin commensal, such analyses often struggled to exclude the alternate possibility that these organisms represent perioperative microbiologic contamination

A study confirms that P. acnes is prevalent in herniated disc tissue. Moreover, it provides the first visual evidence of P. acnes biofilms within such specimens, consistent with infection rather than microbiologic contamination 1).


The presence of 36/46 modic changes in patients with lumbar disc herniation, positive for P. acnes suggests that P. acnes can lead to edema on the vertebrae endplates near to infected area 2).


In a study, 145 patients including 25 cases with cervical and 120 cases with lumbar disc herniation were enrolled. There was no significant difference in the age of male and female patients (p = 0.123). P. acnes infection was detected in nine patients (36%) with cervical disc herniation and 46 patients (38.3%) with lumbar disc herniation and no significant differences were reported in P. acnes presence according to the disc regions (p = 0.508.). Moreover, there was a significant difference in the presence of P. acnes infection according to the level of lumbar disc herniation (p = 0.028).

According to the results, the presence of P. acnes is equal in patients with cervical and lumbar disc herniation. There was a significant difference in the distribution of P. acnes infection according to level of lumbar disc herniation 3).

Case series

Clinical data obtained from 14 cases of P. acnes infection and 28 controls infected with other pathogens were analyzed. Craniotomy, malignancy, and prolonged duration of operation were significantly associated with the onset of P. acnes infection. No fatal cases were reported 4).

Case reports

2017

Hemiparesis may be the result of lesions in the contralateral pyramidal tract in the brain or, less frequently, in the ipsilateral pyramidal tract in the upper cervical spinal cord. However, although rare, multiple lesions that simultaneously occur in both of these regions may be the cause of acute hemiparesis, and the clinical symptoms can often be misdiagnosed as a stroke. In addition, the correct diagnosis of these multiple central nervous system (CNS) lesions is very challenging if they are caused by infection from an unexpected microorganism. We evaluated an elderly healthy woman who presented with acute hemiparesis and multiple brain and spinal cord lesions that were confirmed to occur from an infection with Propionibacterium acnes. In this report, the differential diagnosis and histopathological findings are discussed for these multiple CNS lesions in this healthy woman 5).

1)

Capoor MN, Ruzicka F, Schmitz JE, James GA, Machackova T, Jancalek R, Smrcka M, Lipina R, Ahmed FS, Alamin TF, Anand N, Baird JC, Bhatia N, Demir-Deviren S, Eastlack RK, Fisher S, Garfin SR, Gogia JS, Gokaslan ZL, Kuo CC, Lee YP, Mavrommatis K, Michu E, Noskova H, Raz A, Sana J, Shamie AN, Stewart PS, Stonemetz JL, Wang JC, Witham TF, Coscia MF, Birkenmaier C, Fischetti VA, Slaby O. Propionibacterium acnes biofilm is present in intervertebral discs of patients undergoing microdiscectomy. PLoS One. 2017 Apr 3;12(4):e0174518. doi: 10.1371/journal.pone.0174518. eCollection 2017. PubMed PMID: 28369127; PubMed Central PMCID: PMC5378350.
2)

Aghazadeh J, Salehpour F, Ziaeii E, Javanshir N, Samadi A, Sadeghi J, Mirzaei F, Naseri Alavi SA. Modic changes in the adjacent vertebrae due to disc material infection with Propionibacterium acnes in patients with lumbar disc herniation. Eur Spine J. 2016 Nov 24. [Epub ahead of print] PubMed PMID: 27885471.
3)

Javanshir N, Salehpour F, Aghazadeh J, Mirzaei F, Naseri Alavi SA. The distribution of infection with Propionibacterium acnes is equal in patients with cervical and lumbar disc herniation. Eur Spine J. 2017 Jul 15. doi: 10.1007/s00586-017-5219-z. [Epub ahead of print] PubMed PMID: 28712017.
4)

Haruki Y, Hagiya H, Takahashi Y, Yoshida H, Kobayashi K, Yukiue T, Tsuboi N, Sugiyama T. Risk factors for Propionibacterium acnes infection after neurosurgery: A case-control study. J Infect Chemother. 2017 Apr;23(4):256-258. doi: 10.1016/j.jiac.2016.10.003. Epub 2016 Nov 23. PubMed PMID: 27889246.
5)

Lee JH, Heo SH, Lee JS, Chang DI, Park KH, Sung JY, Hong IK, Kim MH, Park BJ, Choi WS. Acute Hemiparesis in a Healthy Elderly Woman: Where and What Is the Lesion? Front Neurol. 2017 Mar 21;8:109. doi: 10.3389/fneur.2017.00109. eCollection 2017. PubMed PMID: 28377743; PubMed Central PMCID: PMC5359233.

Update: NeuroVR

CAE Healthcare NeuroVR Surgical Simulator from CAE Healthcare on Vimeo.

https://caehealthcare.com/surgical-simulation/neurovr


Simulation technology identifies neurosurgical residency applicants with differing levels of technical ability. These results provide information for studies being developed for longitudinal studies on the acquisition, development, and maintenance of psychomotor skills. Technical abilities customized training programs that maximize individual resident bimanual psychomotor training dependant on continuously updated and validated metrics from virtual reality simulation studies should be explored 1).


“Experts” display significantly more automaticity when operating on identical simulated tumors separated by a series of different tumors using the NeuroVR platform. These results support the Fitts and Posner model of motor learning and are consistent with the concept that automaticity improves after completing residency training. The potential educational application of the findings is outlined related to neurosurgical resident training 2).


Ultrasonic aspirator force application was continually assessed during resection of simulated brain tumors by neurosurgeons, residents, and medical students. The participants performed simulated resections of 18 simulated brain tumors with different visual and haptic characteristics. The raw data, namely, coordinates of the instrument tip as well as contact force values, were collected by the simulator. To provide a visual and qualitative spatial analysis of forces, the authors created a graph, called a force pyramid, representing force sum along the z-coordinate for different xy coordinates of the tool tip.

Sixteen neurosurgeons, 15 residents, and 84 medical students participated in the study. Neurosurgeon, resident and medical student groups displayed easily distinguishable 3D “force pyramid fingerprints.” Neurosurgeons had the lowest force pyramids, indicating application of the lowest forces, followed by resident and medical student groups. Handedness, ergonomics, and visual and haptic tumor characteristics resulted in distinct well-defined 3D force pyramid patterns.

Force pyramid fingerprints provide 3D spatial assessment displays of instrument force application during simulated tumor resection. Neurosurgeon force utilization and ergonomic data form a basis for understanding and modulating resident force application and improving patient safety during tumor resection 3).

1)

Winkler-Schwartz A, Bajunaid K, Mullah MA, Marwa I, Alotaibi FE, Fares J, Baggiani M, Azarnoush H, Zharni GA, Christie S, Sabbagh AJ, Werthner P, Del Maestro RF. Bimanual Psychomotor Performance in Neurosurgical Resident Applicants Assessed Using NeuroTouch, a Virtual Reality Simulator. J Surg Educ. 2016 Nov – Dec;73(6):942-953. doi: 10.1016/j.jsurg.2016.04.013. Epub 2016 Jul 7. PubMed PMID: 27395397.
2)

Bugdadi A, Sawaya R, Olwi D, Al-Zhrani G, Azarnoush H, Sabbagh AJ, Alsideiri G, Bajunaid K, Alotaibi FE, Winkler-Schwartz A, Del Maestro R. Automaticity of Force Application During Simulated Brain Tumor Resection: Testing the Fitts and Posner Model. J Surg Educ. 2017 Jul 3. pii: S1931-7204(17)30114-9. doi: 10.1016/j.jsurg.2017.06.018. [Epub ahead of print] PubMed PMID: 28684100.
3)

Azarnoush H, Siar S, Sawaya R, Zhrani GA, Winkler-Schwartz A, Alotaibi FE, Bugdadi A, Bajunaid K, Marwa I, Sabbagh AJ, Del Maestro RF. The force pyramid: a spatial analysis of force application during virtual reality brain tumor resection. J Neurosurg. 2017 Jul;127(1):171-181. doi: 10.3171/2016.7.JNS16322. Epub 2016 Sep 30. PubMed PMID: 27689458.

Update: Navigated transcranial magnetic stimulation for language mapping

In respect to language mapping with repetitive nTMS, literature reports have yielded variable results, and it is currently not routinely performed for presurgical language localization.

The expert panel recommends nTMS motor mapping in routine neurosurgical practice, as it has a sufficient level of evidence supporting its reliability. The panel recommends that nTMS language mapping be used in the framework of clinical studies to continue refinement of its protocol and increase reliability 1).

Although language mapping by repetitive navigated transcranial magnetic stimulation (rTMS) gains importance in neuropsychological research and clinical utility, neuroscientists still use different mapping protocols including different stimulation frequencies.

The stimulation frequency has to be adapted to the aim of the rTMS language investigation 2).

2015

Ille et al. performed multimodal language mapping in 35 patients with left-sided perisylvian lesions by using rTMS, fMRI, and DCS. The rTMS mappings were conducted with a picture-to-trigger interval (PTI, time between stimulus presentation and stimulation onset) of either 0 or 300 msec. The error rates (ERs; that is, the number of errors per number of stimulations) were calculated for each region of the cortical parcellation system (CPS). Subsequently, the rTMS mappings were analyzed through different error rate thresholds (ERT; that is, the ER at which a CPS region was defined as language positive in terms of rTMS), and the 2-out-of-3 rule (a stimulation site was defined as language positive in terms of rTMS if at least 2 out of 3 stimulations caused an error). As a second step, the authors combined the results of fMRI and rTMS in a predefined protocol of combined noninvasive mapping. To validate this noninvasive protocol, they correlated its results to DCS during awake surgery.

The analysis by different rTMS ERTs obtained the highest correlation regarding sensitivity and a low rate of false positives for the ERTs of 15%, 20%, 25%, and the 2-out-of-3 rule. However, when comparing the combined fMRI and rTMS results with DCS, the authors observed an overall specificity of 83%, a positive predictive value of 51%, a sensitivity of 98%, and a negative predictive value of 95%.

In comparison with fMRI, rTMS is a more sensitive but less specific tool for preoperative language mapping than DCS. Moreover, rTMS is most reliable when using ERTs of 15%, 20%, 25%, or the 2-out-of-3 rule and a PTI of 0 msec. Furthermore, the combination of fMRI and rTMS leads to a higher correlation to DCS than both techniques alone, and the presented protocols for combined noninvasive language mapping might play a supportive role in the language-mapping assessment prior to the gold-standard intraoperative DCS 3).

2013

nTMS and MEGI were performed on 12 subjects. nTMS yielded 21 positive language disruption sites (11 speech arrest, 5 anomia, and 5 other) while DCS yielded 10 positive sites (2 speech arrest, 5 anomia, and 3 other). MEGI isolated 32 sites of peak activation with language tasks. Positive language sites were most commonly found in the pars opercularis for all three modalities. In 9 instances the positive DCS site corresponded to a positive nTMS site, while in 1 instance it did not. In 4 instances, a positive nTMS site corresponded to a negative DCS site, while 169 instances of negative nTMS and DCS were recorded. The sensitivity of nTMS was therefore 90%, specificity was 98%, the positive predictive value was 69% and the negative predictive value was 99% as compared with intraoperative DCS. MEGI language sites for verb generation and object naming correlated with nTMS sites in 5 subjects, and with DCS sites in 2 subjects. CONCLUSION: Maps of language function generated with nTMS correlate well with those generated by DCS. Negative nTMS mapping also correlates with negative DCS mapping. In our study, MEGI lacks the same level of correlation with intraoperative mapping; nevertheless it provides useful adjunct information in some cases. nTMS may offer a lesion-based method for noninvasively interrogating language pathways and be valuable in managing patients with peri-eloquent lesions 4).


Twenty patients with tumors in or close to left-sided language eloquent regions were examined by repetitive nTMS before surgery. During awake surgery, language-eloquent cortex was identified by DCS. nTMS results were compared for accuracy and reliability with regard to DCS by projecting both results into the cortical parcellation system.

Presurgical nTMS maps showed an overall sensitivity of 90.2%, specificity of 23.8%, positive predictive value of 35.6%, and negative predictive value of 83.9% compared with DCS. For the anatomic Broca’s area, the corresponding values were a sensitivity of 100%, specificity of 13.0%, positive predictive value of 56.5%, and negative predictive value of 100%, respectively.

Good overall correlation between repetitive nTMS and DCS was observed, particularly with regard to negatively mapped regions. Noninvasive inhibition mapping with nTMS is evolving as a valuable tool for preoperative mapping of language areas. Yet its low specificity in posterior language areas in the current study necessitates further research to refine the methodology 5).

1)

Krieg SM, Lioumis P, Mäkelä JP, Wilenius J, Karhu J, Hannula H, Savolainen P, Lucas CW, Seidel K, Laakso A, Islam M, Vaalto S, Lehtinen H, Vitikainen AM, Tarapore PE, Picht T. Protocol for motor and language mapping by navigated TMS in patients and healthy volunteers; workshop report. Acta Neurochir (Wien). 2017 Jul;159(7):1187-1195. doi: 10.1007/s00701-017-3187-z. Epub 2017 Apr 29. Review. PubMed PMID: 28456870.
2)

Hauck T, Tanigawa N, Probst M, Wohlschlaeger A, Ille S, Sollmann N, Maurer S, Zimmer C, Ringel F, Meyer B, Krieg SM. Stimulation frequency determines the distribution of language positive cortical regions during navigated transcranial magnetic brain stimulation. BMC Neurosci. 2015 Feb 18;16(1):5. PubMed PMID: 25880838.
3)

Ille S, Sollmann N, Hauck T, Maurer S, Tanigawa N, Obermueller T, Negwer C, Droese D, Zimmer C, Meyer B, Ringel F, Krieg SM. Combined noninvasive language mapping by navigated transcranial magnetic stimulation and functional MRI and its comparison with direct cortical stimulation. J Neurosurg. 2015 Jul;123(1):212-25. doi: 10.3171/2014.9.JNS14929. Epub 2015 Mar 6. PubMed PMID: 25748306.
4)

Tarapore PE, Findlay AM, Honma SM, Mizuiri D, Houde JF, Berger MS, Nagarajan SS. Language mapping with navigated repetitive TMS: proof of technique and validation. Neuroimage. 2013 Nov 15;82:260-72. doi: 10.1016/j.neuroimage.2013.05.018. Epub 2013 May 20. PubMed PMID: 23702420; PubMed Central PMCID: PMC3759608.
5)

Picht T, Krieg SM, Sollmann N, Rösler J, Niraula B, Neuvonen T, Savolainen P, Lioumis P, Mäkelä JP, Deletis V, Meyer B, Vajkoczy P, Ringel F. A comparison of language mapping by preoperative navigated transcranial magnetic stimulation and direct cortical stimulation during awake surgery. Neurosurgery. 2013 May;72(5):808-19. doi: 10.1227/NEU.0b013e3182889e01. PubMed PMID: 23385773.

Register Today for This Free Webinar: Strategic Use of BCNU Wafers in Contemporary Care

Register Today for This Free Webinar: Strategic Use
of BCNU Wafers in Contemporary Care

Aug. 23, 2017, at 7 p.m. EDT
Aug. 30, 2017, at 6 p.m. PDT

Register Now >

Faculty

Lynn Stuart Ashby, MD
Assistant Director, Neuro Oncology Program
Barrow Neurological Institute (BNI)
Phoenix, AZ

Eyas M. Hattab, MD, MBA
AJ Miller Professor and Chair
Pathology and Laboratory Medicine
Louisville, KY

Timothy C. Ryken, MD, MS, FACS, FAANS
Professor and Chief
Section of Neurosurgery
Dartmouth-Hitchcock Medical Center
Lebanon, NH

In this one-hour webinar, participants will receive an overview on the practical use of BCNU Wafers for the treatment of newly diagnosed high-grade malignant glioma as an adjunct to surgery and radiation and recurrent glioblastoma multiforme as an adjunct to surgery. Neurooncology, neuropathology and neurosurgery perspectives will be presented in the discussion covering peri-operative considerations for BCNU Wafer implantation as part of a multimodal treatment plan.

Learning Objectives

  • Review historical changes in incidence and survival over recent decades for high grade malignant glioma (HGG) and summarize current FDA approved treatments.
  • Evaluate pivotal evidence for the use of BCNU wafers and indications for newly diagnosed and recurrent HGG setting.
  • Develop strategic approach for integrating BCNU wafers into multimodal standard treatment for patients at diagnosis and relapse of HGG.
  • Discuss prerequisites for successful intraoperative consultation (IOC) outcomes and overcoming challenges in surgical neuropathology.
  • Learn how to bridge the intraoperative gap between pathology and neurosurgery.
  • Identify the best operative and post-operative approaches toward optimizing outcomes following BCNU wafer implantation.

IMPORTANT SAFETY INFORMATION
GLIADEL Wafer can cause fetal harm when administered to a pregnant woman. It is recommended that patients receiving GLIADEL Wafer discontinue nursing. Female patients of reproductive potential should receive counseling on pregnancy planning and prevention. Advise male patients of the potential risk of infertility and to seek counseling on fertility and family planning options prior to implantation of GLIADEL Wafer.
WARNINGS AND PRECAUTIONS
Seizures: Seizures occurred in 37% of patients treated with GLIADEL Wafers in the recurrent disease trial. New or worsening (treatment emergent) seizures occurred in 20% of patients; 54% of treatment-emergent seizures occurred within the first 5 post-operative days. The median time to onset of the first new or worsened post-operative seizure was 4 days. Institute optimal anti-seizure therapy prior to surgery. Monitor patients for seizures postoperatively.
Intracranial Hypertension: Brain edema occurred in 23% of patients treated with GLIADEL Wafers in the initial surgery trial. Additionally, one GLIADEL-treated patient experienced intracerebral mass effect unresponsive to corticosteroids which led to brain herniation. Monitor patients closely for intracranial hypertension related to brain edema, inflammation, or necrosis of the brain tissue surrounding the resection. In refractory cases, consider re-operation and removal of GLIADEL Wafers or Wafer remnants.
Impaired Neurosurgical Wound Healing: Impaired neurosurgical wound healing including wound dehiscence, delayed wound healing, and subdural, subgleal, or wound effusions occur with GLIADEL Wafer treatment. In the initial disease trial, 16% of GLIADEL Wafer-treated patients experienced impaired intracranial wound healing and 5% had cerebrospinal fluid leaks. In the recurrent disease trial, 14% of GLIADEL Wafer-treated patients experienced wound healing abnormalities. Monitor patients post-operatively for impaired neurosurgical wound healing.
Meningitis: Meningitis occurred in 4% of patients receiving GLIADEL Wafers in the recurrent disease trial. Two cases of meningitis were bacterial; one patient required removal of the Wafers four days after implantation; the other developed meningitis following reoperation for recurrent tumor. One case was diagnosed as chemical meningitis and resolved following steroid treatment. In one case the cause was unspecified, but meningitis resolved following antibiotic treatment. Monitor postoperatively for signs of meningitis and central nervous system infection.
Wafer Migration: GLIADEL Wafer migration can occur. To reduce the risk of obstructive hydrocephalus due to wafer migration into the ventricular system, close any communication larger than the diameter of a Wafer between the surgical resection cavity and the ventricular system prior to Wafer implantation. Monitor patients for signs of obstructive hydrocephalus.
ADVERSE REACTIONS
The most common adverse reactions in Newly-Diagnosed High Grade Malignant Glioma patients (incidence >10% and between arm difference ≥4%) are cerebral edema, asthenia, nausea, vomiting, constipation, wound healing abnormalities and depression.
The most common adverse reactions in Recurrent Glioblastoma Multiforme patients (incidence >10% and between arm difference ≥4%) are urinary tract infection, wound healing abnormalities and fever.

Please click here for full Prescribing Information.

PP-GLD-US-0210
Gliadel® is manufactured by Eisai Inc. for Arbor Pharmaceuticals, LLC.
Gliadel® is a registered trademark of Eisai Inc.

Update: Scalp arteriovenous malformation

An arteriovenous malformation (AVM) of the scalp is an abnormal fistulous connection between the feeding arteries and draining veins, without an intervening capillary bed within the subcutaneous layer.

Historically their unusual portly appearance led to various synonyms being coined for the entity viz., aneurysm cirsoide, aneurysm serpentinum, aneurysm racemosum, aneurysm by anastmoses, aneurysmal varix, arteriovenous fistula, plexiform angioma 1).

Epidemiology

Scalp AVM (SAVM) is a rare condition 2) 3).

Etiology

Its origin can be congenital or traumatic.

Congenital arteriovenous malformations (AVMs) of scalp are rare. They are usually not symptomatic at birth and are often misdiagnosed as haemangiomas. To date, only two cases of symptomatic neonatal scalp AVM have been reported in literature. Pathophysiology of congenital AVM is not completely understood but genetic and acquired causes are implicated. Diagnosis and management are often difficult and require multidisciplinary approach. Hussain et al. report a rare case of symptomatic congenital scalp AVM in a 10-day-old neonate who was successfully managed 4).

Clinical features

The clinical picture presents with complaints of increased scalp, scalp disfigurement, pain and neurological symptoms.

They can present a subcutaneous scalp lump or a large, pulsatile mass with a propensity to skin erosion and massive haemorrhage 5) 6).

Treatment

The treatment of sAVF is difficult, and many therapeutic approaches have been proposed. General approaches for the treatment of sAVF include ligation of the feeding arteries, surgical removal, electrothrombosis, embolization, and a combination of these approaches.

Although surgical excision is considered as definitive treatment for these lesions, troublesome intraoperative bleeding may pose a challenge.

Embolization as an alternative modality is gaining popularity.

Although most SAVMs can be operated by traditional method of excision, use of temporary clipping of feeding arteries (like Superficial temporal artery[STA], External carotid artery[ECA]) enables total excision of giant SAVMs with minimal blood loss for a definitive cure. This technique obviates the need for preoperative embolization 7).

Case series

2017

Gangadharaswamy et al. present their experience in the surgical management of 3 cases with SAVMs using proximal feeding artery temporary occlusion followed by total surgical excision. The clinical presentations and radiological features of these cases are discussed in the article. Intraoperative blood loss was less than 150ml in all patients. Postoperative period was uneventful with no morbidity or mortality.

Intraoperative bleeding during surgical excision of scalp AVMs can be troublesome and challenging. To combat this, the authors advocate proximal feeding artery temporary clipping prior to surgical excision of the lesion. The external carotid artery was temporarily clipped in one case and superficial temporal artery in two patients.

Although most SAVMs can be operated by traditional method of excision, use of temporary clipping of feeding arteries (like Superficial temporal artery[STA], External carotid artery[ECA]) enables total excision of giant SAVMs with minimal blood loss for a definitive cure. This novel technique obviates the need for preoperative embolization 8).

2013

Chowdhury et al., reported the experience of the surgical management of such lesions with a short review of the literature.

In this prospective study, 11 patients with scalp AVM and SVM, who underwent surgical excision of lesion in our hospital from 2006 to 2012, were included. All suspected high-flow AVM were investigated with the selective internal and external carotid digital subtraction angiogram (DSA) ± computed tomography (CT) scan of brain with CT angiogram or magnetic resonance imaging (MRI) of brain with MR angiogram, and all suspected low-flow vascular malformation (VM) was investigated with MRI of brain + MR angiogram. Eight were high-flow and three were low-flow VM.

All lesions were successfully excised. Scalp cosmetic aspects were acceptable in all cases. There was no major post-operative complication or recurrence till last follow-up.

With preoperative appropriate surgical planning, scalp AVM and SVM can be excised without major complication 9).

2004

Eight patients with scalp vascular malformations admitted between 1997 and 2002.

All the patients were investigated with selective internal and external carotid angiography. Depending upon the origin of feeding arteries, the scalp vascular malformations were classified into two categories: Group I: the primary scalp arteriovenous malformations and Group II: secondary venous dilatations. Six patients belonged to Group I and two patients were in Group II.

Five patients belonging to Group I underwent successful excision of the arteriovenous malformation. There was no recurrence in this group. Of the two patients in Group II, one patient who had scalp vascular dilatation simulating a primary scalp vascular malformation underwent excision of the lesion. This patient developed severe postoperative brain edema and died.

Primary scalp vascular malformation can be excised safely. However, excision of secondary scalp venous dilatation without treatment of the intracranial component can be dangerous 10).

2002

Muthukumar et al. treated 11 patients with cirsoid aneurysms surgically. All except one patient were males who were in the second and third decades of life. History of trauma was present in 6 patients. In one patient, the lesion had been present since birth. Occipital and frontal regions were the sites commonly involved. Superficial temporal, occipital and posterior auricular arteries were the most frequent feeding arteries. The size ranged from 3 cms to 12 cms. Following investigations were done: CT, MRI, MRA, angiography and Doppler studies.

Excision of the lesion was done in 8 patients and en bloc resection of the lesion with the scalp with reconstruction was done in the remaining three. One among the three patients who underwent en bloc resection had undergone prior surgery. None of the patients underwent preoperative endovascular treatment. One patient had undergone intralesional injection of sclerosing agents twice. Superficial scalp necrosis occurred in two patients but was treated successfully. All the patients except one had good cosmetic results and there was no recurrence during an average follow up of 18 months 11).

1998

A retrospective review of 81 patients with extracranial arteriovenous malformation of the head and neck who presented to the Vascular Anomalies Program in Boston over the last 20 years. This study focused on the natural history and effectiveness of treatment. The male to female ratio was 1:1.5. Arteriovenous malformations occur in anatomic patterns. Sixty-nine percent occurred in the midface, 14 percent in the upper third of the face, and 17 percent in the lower third. The most common sites were cheek (31 percent), ear (16 percent), nose (11 percent), and forehead (10 percent). A vascular anomaly was apparent at birth in 59 percent of patients (82 percent in men, 44 percent in women). Ten percent of patients noted onset in childhood, 10 percent in adolescence, and 21 percent in adulthood. Eight patients first noted the malformation at puberty, and six others experienced exacerbation during puberty. Fifteen women noted appearance or expansion of the malformation during pregnancy. Bony involvement occurred in 22 patients, most commonly in the maxilla and mandible. In seven patients, the bone was the primary site; in 15 other patients, the bone was involved secondarily. Arteriovenous malformations were categorized according to Schobinger clinical staging: 27 percent in stage I (quiescence), 38 percent in stage II (expansion), and 38 percent in stage III (destruction). There was a single patient with stage IV malformation (decompensation). Stage I lesions remained stable for long periods. Expansion (stage II) was usually followed by pain, bleeding, and ulceration (stage III). Once present, these symptoms and signs inevitably progressed until the malformation was resected. Resection margins were best determined intraoperatively by the bleeding pattern of the incised tissue and by Doppler. Subtotal excision or proximal ligation frequently resulted in rapid progression of the arteriovenous malformation. The overall cure rate was 60 percent, defined as radiographic absence of arteriovenous malformation. Cure rate for small malformations was 69 percent with excision only and 62 percent for extensive malformations with combined embolization-resection. The cure rate was 75 percent for stage I, 67 percent for stage II, and 48 percent for stage III malformations. Outcome was not affected significantly by age at treatment, sex, Schobinger stage, or treatment method. Mean follow-up was 4.6 years 12).

1995

Twenty-four patients with cirsoid aneurysms of the scalp. For nine patients (38%), the lesions were related to trauma. Each of the patients presented with a pulsatile scalp swelling with a bruit. No focal neurological deficits were noted in any of the patients. Scalp malformations in all patients were confirmed by selective internal and external carotid angiography, with no intracerebral component revealed in any of the patients. Twenty-one patients had the lesions surgically excised, with good results. The remaining three refused surgical intervention. Meticulous surgical technique, which includes removal of the pericranial component of the malformation, was paramount 13).

1989

Ten patients with scalp arteriovenous fistulas associated with a large varix (cirsoid aneurysms) were treated with a combination of interventional neuroradiologic procedures. These procedures included transarterial embolization, transarterial embolization followed by surgical excision, and two new methods of treatment of cirsoid aneurysms: transvenous embolization and direct puncture of the fistula for embolization. The embolic materials included liquid adhesive agents, particulate agents, detachable balloons, and wire coils. The embolization was performed to lodge the embolic agents in the fistula or proximal draining vein, not just the feeding vessels. Surgery was performed in two cases to remove a small residual nidus of fistula that could not be completely treated with intravascular embolization. With the use of these forms of treatment, cures were obtained in seven patients, and clinical and angiographic improvement was achieved in three patients. No major morbidity, blood loss, or mortality occurred during the treatment of these patients. The follow-up period ranged from 1 month to 8 years 14).

Case reports

2016

A 21-year-old man presented with a right-sided bruit and an enlarging palpable, pulsatile scalp mass. Magnetic resonance imaging demonstrated a 5-cm right sAVM and an azygos anterior cerebral artery (ACA) feeding a 2-cm parafalcine vascular anomaly, as well as an unruptured 3-mm, flow-related, distal ACA aneurysm. sAVM feeders were catheterized and embolized with Onyx 18. During resection of the right frontal scalp lesion, dissection below the pericranium was developed to expose the low-flow extracranial sAVM. A supratrochlear arterial feeder and the vascular nidus were coagulated, but radical resection was avoided to prevent scalp necrosis. An anterior right frontal parasagittal craniotomy and dural opening were performed. A developmental anomaly of the right superior frontal gyrus was noted, and a dense vascular network within the anterior parafalcine fold was excised and coagulated. The distal ACA aneurysm was cauterized and wrapped to preserve the parent artery. The patient made an excellent recovery without neurologic deficits.

A review of the literature demonstrated a variety of endovascular and open surgical treatments with limited consensus on standard care. While sAVMs have been described in the literature, the combination of the diverse conditions seen in this case is unique 15).


Worm et al, present a case of giant scalp AVMs and its management, followed by a brief literature review on the subject. The diagnosis of scalp AVMs is based on physical examination and confirmed by internal and external carotid angiography or computed tomographic angiography (CTA). Surgical excision is especially effective in scalp AVMs, and is the most frequently used treatment modality 16).

2009

Massimi et al. report on the unusual case of a child harboring a complex intracranial AVM that initially presented as a small scalp mass. Actually, this young boy came to the authors’ attention just for a small, soft, pulsatile, and reducible mass of the vertex that produced a circumscribed bone erosion. The presence of macrocranium and venous engorgement of the face, however, suggested the presence of an intracranial “mass.” The neuroimaging investigations pointed out a temporal AVM causing dilation of the intracranial sinuses and ectasia of the vein of the scalp; one of the veins was appreciable as a lump on the vertex 17).

2008

A 35-year-old man presented with occipital subcutaneous pulsatile thrill. Senoglu et al. discussed and illustrated a rare sAVF, which was a high-flow sAVF fed by the occipital branch of the right ACE draining intraosseously into the SS. The case was treated by surgical origin ligation.

This case was unusual in the sense that it was apparently spontaneous, and the major venous drainage was through the bone into the SS. Arterial supply pattern of sAVF is very important in therapeutic decision-making. We suggest that surgical origin ligation for sAVF be considered if the case has 1 feeding artery 18).

2007

Craniofacial cirsoid aneurysm: 2-stage treatment 19).

2004

A 21-year-old female consulted in 1998 complaining of right tinnitus and a pulsating mass in the retroauricular region. The initial angiogram revealed an AVM in the right temporo-parietal subcutaneous space with feeders from the STA, an occipital artery, a posterior auricular artery, and a middle meningeal artery (MMA). Three years later, she complained of enlargement of the lesion, increased tinnitus, and alopecia. Repeat angiographic study revealed the presence of a nidus and the appearance of new feeders from a contralateral MMA and an ipsilateral middle cerebral artery; there was a de novo saccular aneurysm in the right STA. On the day preceding surgery, the left MMA was embolized to control intraoperative bleeding. The AVM was removed totally without any dermal complications.

This case suggests that scalp AVMs can become enlarged by capturing subcutaneous or intracranial feeders, and that the consequent hemodynamic stress may induce de novo aneurysms in scalp AVMs. Capillary endothelial cells were strongly immunostained for vascular endothelial growth factor 20).

1990

Heilman et al. report a patient in whom a large traumatic cirsoid aneurysm of the scalp was eliminated using a combined neurosurgical and interventional neuroradiological approach. Transarterial embolization was utilized to reduce arterial blood supply to the fistula. Thrombogenic Gianturco spring coils were then introduced via direct percutaneous puncture of the aneurysm. The aneurysm thrombosed and the multiple tortuous scalp vessels disappeared. One month after embolization, a small area of skin necrosis over the aneurysm necessitated surgical excision of the lesion. The thrombosed aneurysm was easily resected with minimal blood loss. Percutaneous embolization with thrombogenic coils in this case was a safe and effective ablative technique 21).

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Tiwary SK, Khanna R, Khanna AK. Craniofacial cirsoid aneurysm: 2-stage treatment. J Oral Maxillofac Surg. 2007 Mar;65(3):523-5. PubMed PMID: 17307602.
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