Scalp Arteriovenous Fistula With Intracranial Communication:
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A 71 year old man presented with a nodule on the vertex of the scalp of 1 year’s duration. The lesion had become soft and tender during the week prior to presentation. He noted that he was experiencing headaches and a buzzing sound in his head. The patient was referred for evaluation of a presumed inflamed cyst.

The patient’s medical history included an intracranial arteriovenous fistula (AVF) treated with endovascular embolization 1 year prior to presentation, 2 substantial falls in childhood with head trauma and loss of consciousness, essential hypertension, and an aortic aneurysm. His medications included amlodipine, lisinopril, amoxicillin, a multivitamin, and grape seed extract.

Physical examination revealed a 2-cm, pink, somewhat rubbery, subcutaneous, nonmobile nodule on the vertex of the scalp. The lesion was not consistent with a common pilar cyst, and an excisional biopsy was performed to exclude malignancy. Upon superficial incision, the lesion bled moderately, and the procedure was immediately discontinued. Hemostasis was obtained, and the patient was sent for ultrasonography of the lesion.

Ultrasonography demonstrated a small hypoechoic nodule measuring up to 0.5 cm containing a tangle of vessels in the subcutaneous soft tissue corresponding to the palpable abnormality. A cerebral angiogram demonstrated a dural AVF of the superior sagittal sinus with multifocal supply that connected with this scalp nodule. The patient was treated by interventional neuroradiology with endovascular embolization, which resulted in complete resolution of the scalp nodule.

This patient has a history of 2 substantial falls in childhood with head trauma and loss of consciousness. Perhaps these traumas initiated a channel through the cranium where an S-AVF with intracranial communication was able to form and may have only become clinically or radiographically detectable once it enlarged due to the altered hemodynamics caused by the intracranial AVF 1 year prior

Each S-AVF possesses unique anatomic features that dictate appropriate management. The prognosis for an S-AVF is extremely variable, and the decision to treat is based on the patient’s symptoms and risk for exsanguinating hemorrhage. Neurosurgical approaches include ligation of the feeding arteries, surgical resection, electrothrombosis, direct intralesional injection of sclerosing agents, and endovascular embolization.

This case emphasizes the importance of including S-AVFs on the dermatologic differential diagnosis of a scalp nodule, especially in patients with any history of intracranial AVF.

Source: https://www.mdedge.com/dermatology/article/232292/mixed-topics/scalp-arteriovenous-fistula-intracranial-communication
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