Flying Squid: pigmentation/necrosis after dural aVF embolisation

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?