The patient is an eleven year old girl who presented with a painful, discolored swelling behind her left ear. She said the swelling had increased noticeably in size over the previous 6 months.

The swollen area, upon physical examination, proved to be a pulsatile mass, with some reddish discoloration. (Fig. 1A) The results of MRI/MRA imaging was consistent with an extra-cranial AVM, with feeders from the anterior and posterior auricular branches. There was suggestion of feeders from branches of the middle meningeal artery.

Selective angiogram confirmed feeders from the anterior and posterior auricular arteries. (Fig. 2A) Super selective embolization was performed of feeders involved in the auricular cascade with penetration into the draining veins, nidus, and distal dedicated feeding arteries. Concurrently, the ear was packed in ice to stop flow to the normal tissue. One-tenth of a cc of non-opacitied NBCA was used to minimize the mass of embolic material and discoloration. This led to the total obliteration of the AVM.

Follow-up, (Fig. 2B) shows obliteration of the AV shunting. Additional angiography is indicated in 6-12 months to confirm obliteration.
Fig. 1A Posterior aspect of Left Ear. 
Fig. 1B Two weeks after embolization the inflammation is gone and the shunt gone by Doppler.
Fig. 2A PA view of Left External Carotid Angiogram showing  posterior and anterior Auricular Arteries in ear, helix and scapha feeding with a dominate fistula.
Fig. 2B Total angiographic obliteration of AVM and fistula with sparing of the Helix cascade( as seen on late films)
Key Points:
  1.  Extra-cranial AVMs can become quite active, and can grow with trauma, puberty, or pregnancy.
  2. Normal tissue blood flow is controlled by tissue temperature, whereas pathological shunts seen in AVM’s are fixed. At temperatures below 20C, there is virtually no flow to normal tissue.It is possible to take advantage of this to spare the normal tissue and target the shunts as in this case.
  3. Angiographic follow-up is needed in all AVM treated cases once the non-invasive imaging has been negative for 6-12 months as it is the only way to confirm cure.
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Internal Carotid Artery Stenosis
A 71 year-old woman woke up with numbness and clumsiness of her right hand. Additionally, she complained of difficulty thinking and often felt like she would fall. On neurological examination she had full strength, but in comparative testing the right hand was weaker. Her past medical history was remarkable for arterial hypertension and coronary heart disease with coronary stenting undertaken 12 years ago. The patient was diagnosed with a proximal left internal carotid artery stenosis (CT angiogram). In addition, brain imaging showed subcortical and cortical ischemic changes and increased Tmax on head CT perfusion imaging (Figures 1) further supporting the diagnosis of a symptomatic carotid artery stenosis.
Figure 1: Ischemic cerebral changes are seen in centrum semiovale and left parietal cortex (top row: brain MRI/FLAIR). Cerebral perfusion imaging with increased Tmax in the left hemisphere (CT perfusion; bottom).
The patient was placed on ASA, statin, and antihypertensive medication. On baseline conventional angiogram, there was reduced visualization of intracranial arteries due to a high-grade left internal carotid artery stenosis. Carotid angioplasty and stenting was performed to restore intracranial circulation with excellent radiological and clinical outcome (Figures 2).  
Figure 2: 71 year-old woman with symptomatic high-grade stenosis of the proximal left internal carotid artery (ICA) (filling defect market as yellow,* top middle). Pre-operative, reduced filling of the left middle cerebral artery (M) and no filling of the anterior cerebral artery (A) (top left). External carotid artery branches, superficial temporal and middle meningeal arteries filling ahead of the intracranial circulation on cerebral angiogram (left). Carotid angioplasty and stenting (center) with restitution of carotid lumen post-op (bottom middle) and restoration of intracranial flow with visualization of branches of middle and anterior cerebral arteries (right). 
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NEUROLOGICAL SURGERY, P.C.
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