Flying Squid: pigmentation/necrosis after dural aVF embolisation

Author: DIESTRO Jose Danielo B

Find out how Dr. Jose Danilo B. Diestro (St. Michael’s Hospital, University of Toronto, Department of Medical Imaging Toronto, Canada) treated a 60-year-old male patient suffering from a pigmentation/necrosis after dural aVF embolization.

• Case

  CASE PRESENTATION

  • Evolution of scan 1 to scan 2 was over a few minutes.
  • Oct 19, 2018: There is a thrombus in the mid superior sagittal sinus 2.6cm in the ap dimension. Extrusion into the vein of Trolard.

  

   

  INITIAL NEUROIMAGING: 10-2018

  

   

  BLEED ETIOLOGY 10-2018 (CTV)

  

   

  FOLLOW-UP: 11-2019

  • Persistence of swelling compared with initial bleed

   

  

   

  FOLLOW-UP CTA: 11-2019

  • Suspicious for dural AVF an entire year after presentation?

   

  

   

  EMBOLIZATION OF aVF

  • Embolization agent: Squid 12
  • Artery: Right Superficial Temporal Artery
  • Distal Access Catheter: 5F Sofia x 115xm
  • 1st: 1.5F Sonic Microcatheter
  • 2nd: 4 x 11mm Scepter Balloon Catheter
  • 3rd: 4 x 11mm Scepter Balloon Catheter

   

  PRE-EMBOLIZATION

   

  

   

  

   

  

   

  POST-EMBOLIZATION

   

  

   

  

   

  

   

  

   

  SQUID IN LABBE

  • Flying squid!

   

  

   

  POST-EMBOLIZATION

   

  

   

  

   

  

   

  

   

  

   

  

   

  

   

  

   

  

   

  CT: SQUID

   

  

   

  BEFORE AND AFTER SQUID

   

  

   

  POST-EMBOLIZATION COURSE

  • He was discharged well a day after the procedure
  • Five days later he noticed a well-delineated black plaque surrounded my erythema on his scalp (site of previous decompressive craniectomy)
  • NO pain or discharge

   

  POST-EMBOLIZATION SKIN EROSION/PIGMENTATION

   

  

   

  COMPLICATIONS

  

   

  FOREHEAD PIGMENTATION

  • Hae Won Koo et al. Forehead pigmentation after Onyx embolization for dural arteriovenous fistula presenting with parkinsonism

  

   

  EAR NECROSIS

  • Jankowitz et al. Ear Necrosis Resulting from the Endovascular Onyx-18 Embolization of a Dural Arteriovenous Fistula Fed by the Posterior Auricular Artery

  

   

  FACIAL NECROSIS

  • Grandhi et al. Facial necrosis after endovascular Onyx‑18 embolization for epistaxis

  

   

  ONYX EXTRUSION

  • Watanabe et al. Onyx removal after embolization of a superior sagittal sinus dural arteriovenous fistula involving scalp artery

  

   

  • Singla et al. Onyx extrusion through the scalp after embolization of dural arteriovenous fistula

  

   

  TAKE-HOME MESSAGES

  • Patients should be well apprised of this possible complication 
  • Less viscous embolization agents may embolize to undesired territories

   

  POINTS FOR DISCUSSION

  • Use of balloon catheters in embolization
  • Etiology of the dural AVF
  • Less viscous embolization agents going past the target?
  • Was the lesion pigmentation or frank necrosis from arterial occlusion?