Department of Surgery, Bicol Medical Center, Naga City, Philippines.
Independent Researcher, Naga City, Philippines.
Vasc Endovascular Surg. 2023 Jul;57(5):532-535. doi: 10.1177/15385744231154990. Epub 2023 Feb 2.
Scalp arteriovenous malformation (AVM) is a rare congenital disease that may present with massive bleeding. To date, surgical excision remains the definitive management. However, the procedure could lead to intraoperative bleeding due to the tumor's high blood flow and complex vascularity.
A 49-year old Filipino male presented with a bleeding giant scalp AVM. Computed tomographic scan and duplex studies showed multiple feeding vessels with turbulent flow arising primarily from the right superficial temporal, right posterior auricular, and occipital vessels. Prior to surgery, the patient underwent transfusion due to preoperative hemoglobin of 6 g/dL. Proximal control of the right external carotid artery was performed through a supine position and left in place to reduce the majority of blood flow to the AVM. The patient was turned to a prone position for surgical planning to achieve maximal skin-sparing dissection prior to excision. First, ligation of bilateral superficial temporal and posterior auricular arteries was performed. Next, excision above the periosteum with segmental ligation of feeding vessels around the AVM was carried out. Reconstruction of the defect was done via scalp advancement flap and split-thickness skin grafting. Intraoperative blood loss was 1.6 L. On the sixth postoperative day, the patient was discharged with 100% graft take.
Management of scalp AV malformation is challenging, and despite measures to decrease intraoperative bleeding, blood loss is still high. While preoperative embolization has been reported to decrease the risk of bleeding, this procedure is not currently available in our setting. Our case highlights the complexity of giant scalp AV malformation management in a limited-resource setting. Even in the absence of endovascular intervention, outright surgical excision of AVM can be performed, albeit with higher levels of blood loss.
头皮动静脉畸形（AVM）是一种罕见的先天性疾病，可导致大出血。迄今为止，手术切除仍然是明确的治疗方法。然而，由于肿瘤血液供应丰富且血管结构复杂，手术过程中可能会导致出血。
一名 49 岁菲律宾男性，因大出血性头皮巨大 AVM 就诊。计算机断层扫描和双功能超声检查显示，多个供血血管存在血流紊乱，主要来自右侧颞浅动脉、耳后动脉和枕动脉。手术前，由于术前血红蛋白为 6g/dL，患者接受了输血。通过仰卧位对右侧颈外动脉近端进行控制，同时保留以减少大部分流向 AVM 的血流。患者改为俯卧位进行手术规划，以实现切除前最大限度的皮肤保留解剖。首先，结扎双侧颞浅动脉和耳后动脉。然后，在骨膜上方进行切除，并结扎 AVM 周围的供血血管。通过头皮推进皮瓣和断层皮片移植进行缺损重建。术中失血量为 1.6L。术后第 6 天，患者痊愈出院，植皮 100%成活。
头皮 AVM 的治疗具有挑战性，尽管采取了措施减少术中出血，但失血量仍然很高。虽然术前栓塞已被报道可降低出血风险，但在我们的环境中，目前尚未开展此操作。我们的病例突出了在资源有限的情况下，巨大头皮 AVM 管理的复杂性。即使没有血管内介入，也可以直接进行 AVM 切除，尽管出血水平更高。
