SIR RFS Case Series: Incidental Finding during Cardiomyopathy Workup
SIR RFS Case Series: A Bump On The Head
Transcript of SIR RFS Case Series: A Bump On The Head
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A BUMP ON THE HEAD***
Resident(s): Christopher Bedford, MD
Attending(s): Michel E. Mawad, MD & Sheena Pimpalwar, MD
Program/Dept(s): Baylor College of Medicine
Originally Posted: May, 01, 2014
*** 2014 SIR Resident-in-Training Case Competition Runner-Up
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CHIEF COMPLAINT & HPI
Chief Complaint and History of Present Illness A 5 year old girl with remote history of trauma to the forehead presented
with a bluish swelling above the left eyebrow that became prominent with Valsalva maneuver. The swelling was compressible, non-tender with no palpable thrill and normal skin temperature.
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RELEVANT HISTORY
Past Medical History Remote history of trauma to the forehead after being dropped by babysitter.
Past Surgical History None
Family & Social History Non contributory
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DIAGNOSTIC WORKUP
Physical Exam Bluish swelling above the left eyebrow
that became prominent with Valsalva maneuver. The swelling was compressible, non-
tender, with no palpable thrill and normal skin temperature
Non-Invasive Imaging MRI Ultrasound
Note scar from laceration (arrow) at 2 years of age (dropped by baby sitter)
Valsalva maneuver
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DIAGNOSTIC WORKUP - QUESTION
T2W and post-contrast MRI images demonstrate:
1) Findings suggestive of a dural arteriovenous malformation.
2) Findings suggestive of a leptomeningeal cyst.
3) Findings suggestive of a subcutaneous venous malformation.
4) Findings suggestive of a calvarial osteosarcoma.
T2W
Post-contrast T1W
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CORRECT!
T2W
Post-contrast T1W
T2W and post-contrast MRI images demonstrate:
1) Findings suggestive of a dural arteriovenous malformation. The abnormality is in a subcutaneous location, and there are no flow voids to suggest an AVM.
2) Findings suggestive of a leptomeningeal cyst. There is no communication of the abnormality with the subarachnoid space.
3) Findings suggestive of a subcutaneous venous malformation.
4) Findings suggestive of a calvarial osteosarcoma. The calvarium is normal in signal and morphology.
CONTINUE WITH CASE
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SORRY, THAT’S INCORRECT.
T2W
Post-contrast T1W
T2W and post-contrast MRI images demonstrate:
1) Findings suggestive of a dural arteriovenous malformation. The abnormality is in a subcutaneous location, and there are no flow voids to suggest an AVM.
2) Findings suggestive of a leptomeningeal cyst. There is no communication of the abnormality with the subarachnoid space.
3) Findings suggestive of a subcutaneous venous malformation.
4) Findings suggestive of a calvarial osteosarcoma. The calvarium is normal in signal and morphology.
CONTINUE WITH CASE
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DIAGNOSTIC WORKUP – COLOR DOPPLER ULTRASOUND
Color doppler ultrasound of the calvarium
Gray scale ultrasound shows a defect in the outer table communicating with the venous sac.
Color Doppler shows an arterial jet arising from the defect entering the venous sac.
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DIAGNOSTIC WORKUP – ANGIOGRAPHY
Left external cartoid angiography shows the anterior deep temporal branch of the internal maxillary artery terminates in a venous sac with rapid drainage into a tributary of the superficial temporal vein.
AV Fistula
Anterior deep temporal branch
Internal maxillary artery
Superficial temporal vein
LAT
Native image
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DIAGNOSIS
Arteriovenous fistula.
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DIAGNOSIS- QUESTION
1) What are the classic clinical findings of AV fistulae?
A: Palpable thrill, audible bruit, cutaneous warmth.
B: Skin discoloration, absence of a palpable thrill, normal skin temperature.
C: Skin discoloration, cutaneous warmth, absence of a bruit.
D: Skin nodules, cutaneous warmth, palpable thrill.
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CORRECT!
1) What are the classic clinical findings of AV fistulae?
A: Palpable thrill, audible bruit, cutaneous warmth.
B: Skin discoloration, absence of a palpable thrill, normal skin temperature.
C: Skin discoloration, cutaneous warmth, absence of a bruit.
D: Skin nodules, cutaneous warmth, palpable thrill.
CONTINUE WITH CASE
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SORRY, THAT’S INCORRECT.
1) What are the classic clinical findings of AV fistulae?
A: Palpable thrill, audible bruit, cutaneous warmth.
B: Skin discoloration, absence of a palpable thrill, normal skin temperature.
C: Skin discoloration, cutaneous warmth, absence of a bruit.
D: Skin nodules, cutaneous warmth, palpable thrill.
CONTINUE WITH CASE
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INTERVENTION
Transarterial embolization: Image A: Selective catheterization of
the anterior deep temporal branch feeding the AV fistula followed by embolization using n- butyl cyanoacrylate (n-BCA). Image B: Color doppler ultrasound
shows successful thrombosis of the lateral half of the venous sac (arrow) with a persistent arterial jet within the medial half of the sac.
Venous sac
A
B
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INTERVENTION
Repeat angiography: Search for further arterial feeders to the
venous sac was negative, hence a percutaneous approach was selected for further embolization
ICA ECA
Internal maxillary artery Middle meningeal artery Superficial temporal artery
Facial artery
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INTERVENTION
Percutaneous venography and embolization: Venous
sac
AV fistula catheterized under ultrasound guidance followed by digital subtraction venography. C-arm CT confirms extracranial location of injected contrast.
Venous sac
2nd procedure: n-BCA injected into venous sac under digital subtraction road map imaging and C-arm CT.
1st procedure: Absolute alcohol injection results in near complete thrombosis of venous sac.
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CLINICAL FOLLOW UP
7 month follow-up: T2W MRI shows no residual
hyperintensity within the left forehead subcutaneous tissue. Complete clinical resolution of the
left forehead swelling even after provocation with Valsalva maneuver.
Pre treatment Post treatment
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SUMMARY & TEACHING POINTS
AV fistulae may be clinically and angiographically occult resulting in challenges in diagnosis and management.
Color Coppler is a very sensitive tool in differentiating low flow from high flow lesions, which influences their management. It also has a valuable role in monitoring the success of embolization.
This case also illustrates the application of several imaging tools (Color Doppler, C-arm CT, high-resolution and fast-frame selective DSA) for better localization of AV fistulae. Such imaging tools ultimately help in obtaining excellent anatomical and clinical results.
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REFERENCES/FUTURE READING
Venkatanarasimha N, Freeman S. Ultrasound features of arteriovenous fistula. AJR Am J Roentgenol. 2010;194(6):W540; author reply W543. doi:10.2214/AJR.09.3978.
Dabus G, Pizzolato R, Lin E, Kreusch A, Linfante I. Endovascular treatment for traumatic scalp arteriovenous fistulas: results with Onyx embolization. J Neurointerv Surg. 2013. doi:10.1136/neurintsurg-2013-010724.