28-year-old patient with a circumscribed swelling on the right side of the forehead which had increased in volume over the past year and had previously presented as redness for a long time. The immediate surrounding skin shows a pale rim due to a steal phenomenon. On palpation, the mass is clearly hyperthermic, and a pulsation is palpable. Thus, a fast-flow malformation is likely. The photograph shows the direct top view.
Digital subtraction angiography (DSA) with contrast injection into the right external carotid artery. The superficial temporal artery reveals a microfistulous AVM with markedly dilated feeder arteries on the right forehead with immediate venous outflow.
After super-selective catheterization via a microcatheter, stepwise filling of the entire nidus of the AVM using ethylene-vinyl alcohol copolymer with plug-and-push technique, in which the catheter tip is glued in place and the embolic agent is pressed into the lesion. Image in roadmap technique shows previously injected embolic agent in white and newly injected embolic agent in black. Note the increasing retrograde filling of the small feeder artery at the bottom of the lesion (start of injection).
The conventional radiograph (same section as previous image) after completion of the embolization shows the complete cast specimen of the entire nidus with the radiopaque embolization material (cast). This accurately traces the anatomy and angiomorphology of the complete AVM, which is thus occluded.
Completion angiography with contrast injection into the right external carotid artery demonstrates complete occlusion of the nidus of the arteriovenous malformation. On account of the subtraction imaging technique, the cast appears white here (subtracted).
The arteriovenous malformation (AVM) on the forehead treated here, although not very large, has entered a proliferation stage (Schobinger grade II) and has shown significant enlargement in the past months. This suggests a poor long-term prognosis without treatment. In addition, there is cosmetic impairment on the forehead.
The therapeutic approach here is a combination of complete embolization and subsequent resection of the occluded nidus of the AVM.
Comparison of the initial angiography images and the image of the cast specimen of the AVM completely filled with embolic agent demonstrate the completeness of the occlusion.
In this case, the probability of recurrence is very low in the long-term course, but follow-up is still necessary in the long term.
All images © Wohlgemuth