A case of pulsatile scalp swelling in a child

Abstract

Arteriovenous fistulas (AVF) are an entity most commonly seen in the head and neck region. An AVF is a direct connection between the arterial feeders and the draining veins without intervening capillary beds (unlike an arteriovenous malformation in which a nidus intervenes between the arteries and veins). We describe a case of traumatic AVF in a child aged 9 years, who presented with a pulsatile scalp swelling following blunt trauma to the head. It turned out to be an AVF between the superficial temporal artery and vein. Correct diagnosis of an AVF involves Doppler examination with digital subtraction angiography providing a good roadmap for treatment, which can be either endovascular or surgical.

Emergent Hybrid Treatment of a Ruptured Scalp Arteriovenous Fistula with Eyelid involvement: Technical Note

“…The right frontal scalp is a frequent location for this pathology, followed by the middle and left frontal scalps. 1,2,4,8 Etiology can be congenital, traumatic, or predisposed by smooth muscle cell disorganization (fibromuscular dysplasia). 2,3 The majority of cases are spontaneous (60.2%), 32.3% are associated with trauma, and 7.5% are classified as iatrogenic.…”

“…The first hypothesis, the disruption theory, is based on endothelial cell proliferation because of the rupture of the vasa vasorum in the wall of an artery, leading to neovascularization and connection with adjacent veins. 4,5,8 The second hypothesis, the laceration theory, states that simultaneous lacerations of a vein and an artery create a direct arteriovenous shunt. 4,5,8 Symptoms of this pathology are variable, and they usually start 5 years before diagnosis.…”

“…Angiography is the gold standard modality for diagnosis. 2,4,5,8 Magnetic resonance imaging (MRI) and computed tomography (CT) scans can help rule out differential diagnoses. Magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are also valuable tools for evaluation of the fistula.…”

“…1,2 Congenital or traumatic etiologies have been described. [3][4][5] Clinical presentation is diverse and depends on the evolution of the disease. History of a progressively increasing pulsatile mass is common, and it can be associated with mild to severe complications including congestive heart failure.…”

Symptomatic scalp fistula present in a 14-month-old toddler

“…A cerebral angiography and an MRI are helpful studies. CT scans and Doppler examinations have also shown to guide neurosurgeons towards the diagnosis 2. Long-term surveillance of vasculature may be required since vascular abnormalities may go undetected for lengths of time during their development.…”