Dermatology Online Journal

Temporary alopecia after embolization of an arteriovenous malformation
Verónica López MD, Inmaculada López MD, José M Ricart MD
Dermatology Online Journal 18 (9): 14

Department of Dermatology, Dermiláser Hospital Quirón Valencia, Spain

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Abstract

Alopecia after head and neck radiotherapy has been extensively reported in the literature. However, alopecia after endovascular procedures is seldom reported in the dermatological literature. Prolonged fluoroscopic imaging during these procedures may cause serious radiation injuries to the skin, such as dermatitis or alopecia. Radiation-induced temporary alopecia is a peculiar form of radiodermitis that occurs over the areas of the scalp that receive the highest doses of radiation. Although repopulation of alopecic patches occurs spontaneously without treatment, it is important to recognize this disorder to establish a correct diagnosis and inform patients about this transient side effect. We report a 44-year-old woman presenting with temporary alopecia after embolization of an arteriovenous malformation.

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Case report

A 44-year-old woman was referred to our department for evaluation of an alopecic patch over the temporoparietal region of the scalp. Her medical history was relevant for the presence of a three-year-history of recurrent headaches secondary to a right occipital arteriovenous malformation previously treated with embolization. Hemiparesia and loss of consciousness appeared after the last procedure. A computed tomography revealed a right occipital intra-parenchymal hematoma, with opening to the ventricular system and a right subdural hematoma. A craniotomy with evacuation of the right subdural hematoma was performed with a placement of an external ventricular drain through the left frontal lobe. The clinical course was favorable and the patient was discharged without neurological complications. However, the malformation was not completely excised and another fluoroscopically guided superselective angiography followed by surgical removal of the residual malformation was required. The total time taken for the procedure was estimated to be 80 minutes and the total radiation dose was over 3 Gy. The patient was discharged on the 6th post-procedure day without any neurological complications. However, she complained of hair loss in the right temporoparietal region of the scalp approximately 3 weeks after the last embolization.

Figure 1	Figure 2
Figure 1. Image showing an area of almost total alopecia in the right temporoparietal region of the scalp. Figure 2. Complete repopulation of radiation-induced alopecic area after four months.

Physical examination revealed an 18 x 6 cm patch of total hair loss on the right temporoparietal region (Figure 1). The scalp was otherwise normal and exclamation-mark hairs were not noted. Pull tests were positive over the areas of hair loss. Her bilateral occipital arteries and superficial temporal arteries remained patent. The diagnosis of temporary alopecia after endovascular procedures diagnosis was established. The hair regrew after 3 months without any treatment (Figure 2).

Discussion

Interventional radiological procedures have increasingly been used in recent years for the treatment of vascular disorders, such as arteriovenous malformation, carotid artery stenosis, intracranial aneurism, or arteriovenous fistula, because of its less morbidity and mortality compared with surgery.

Alopecia after head and neck radiotherapy has been extensively reported in the literature. However, alopecia after endovascular procedures is seldom reported [1-8]. Prolonged fluoroscopic imaging during these procedures may cause serious radiation injuries to the skin, such as dermatitis or alopecia. Radiation-induced temporary alopecia is a peculiar form of radiodermitis, with an estimated threshold dose of 3 Gy, above which the probability of the occurrence of skin lesions increases rapidly. The location of the alopecic areas is related to the dose delivered during embolization and occurs over the scalp region that receives the highest doses of radiation therapy during fluoroscopy. Thus, prolonged exposure and high doses during endovascular procedures can lead to significant radiation-induced side effects. Therefore, the International Commission on Radiological Protection recommends recording the maximum entrance skin dose and its location if the dose exceeds 1 Gy or 3 Gy in interventional procedures [9]. Moreover, the FDA recommends that the absorbed skin dose should be recorded in the patient's medical record [9].

Radiation-induced alopecia depends on the high susceptibility of hair follicles to radiation. Acute damage to actively dividing matrix cells of anagen follicles causes the loss of dystrophic hair, followed, in addition, by a premature enter of follicles in late anagen subphases into the transient catagen phase, and then into the telogen phase, leading to the premature shedding of hair [4].

Irradiation-induced alopecia should not be confused with pressure alopecia and alopecia areata. Repopulation of radiation-induced alopecic areas occurs spontaneously generally after a mean time of 2 to 4 months after irradiation and no treatment is required. The most important measure is prevention to limit exposure to the least amount necessary to complete the procedure [9].

In conclusion, because of the increase of minimal endovascular procedures for diagnosis and treatment of vascular disorders, alopecia after embolization should be recognized to establish a correct diagnosis, inform, and reassure patients about this transient side effect.

References

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