INR scope

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.

Monday 14 March 2022
  • 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.
    Squid

     

    INITIAL NEUROIMAGING: 10-2018

    Squid

     

    BLEED ETIOLOGY 10-2018 (CTV)

    Squid

     

    FOLLOW-UP: 11-2019

    • Persistence of swelling compared with initial bleed

     

    Squid

     

    FOLLOW-UP CTA: 11-2019

    • Suspicious for dural AVF an entire year after presentation?

     

    Squid

     

    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

     

    Squid

     

    Squid

     

    Squid

     

    POST-EMBOLIZATION

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    SQUID IN LABBE

    • Flying squid!

     

    Squid

     

    POST-EMBOLIZATION

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    Squid

     

    CT: SQUID

     

    Squid

     

    BEFORE AND AFTER SQUID

     

    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

     

    Squid

     

    COMPLICATIONS

    Squid

     

    FOREHEAD PIGMENTATION

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

     

    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
    Squid

     

    FACIAL NECROSIS

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

     

    ONYX EXTRUSION

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

     

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

     

    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?
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