Control # 209 Title: Life -Threatening Lytic lesion of the Mandible: A Lesson Learned - PowerPoint Presentation

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Control #

209

Title:

Life -Threatening Lytic lesion of the Mandible: A Lesson Learned

eEdE

#

eEdE-157

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Nothing To Disclose

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Life-Threatening Lytic lesion of the Mandible “A Lesson Learned”

Nucharin Supakul, MD1Juan G Tejada, MD2

1. Ramathibodi Hospital, Mahidol UniversityBangkok, Thailand2. Indiana University School of Medicine,Eskenazi HealthIndianapolis, Indiana, USA

Slide4

Purpose

To review the characteristic imaging findings of mandibular vascular malformations

and

avoid unnecessary

and risky biopsies of the

mandibular

lesions.

To demonstrate interventional treatment options for vascular lesions in the mandible in life-threatening conditions and also in the preoperative setting.

Slide5

Introduction

Mandibular Vascular

lesions are divided

in 2

groups

Hemangioma

Failure of

differentiation in the early stages of

embryogenesis

Appears in childhood and

regresses

over

time

Rarely associated with

fatal hemorrhage

Vascular malformation

Disturbance in the late stage of angiogenesis (

truncal

stage) and

results

in persistence of arteriovenous anastomosis

Present at birth and

grows

over

time

Symptoms

depend

on hemodynamic

factors

High flow: AVM, AVF

Fatal hemorrhage

Low flow: Lymphatic, venous, or mixed

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Mandibular AVM

Abnormal direct communication between arteries and veins, bypassing capillary bed

Location:

Usually posterior location within the ramus and posterior mandibular body

Clinical presentation

Gingival bleeding (most common)

Massive bleeding with shock following by the extraction of teeth (most common)

Soft tissue mass (pulsatile/ non pulsatile), bruit, thrill

Painful, alteration of facial morphology

Neurosensory deficit

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Imaging Findings

Cystic radiolucent lesion

Honeycomb (

multilocular

) or soap bubble appearance

Resorption of the adjacent bone/ dental root

 teeth floating in the adjacent alveolar osseous erosion

Mimics odontogenic/non-odontogenic lesions

Central giant

cell granuloma

Ossifying fibroma

Traumatic bone cyst

Ameloblastoma

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Imaging Findings

CT and MRI

Evaluates

the extent of the lesion

Bone erosion

Involvement of major vessels

Catheter angiogram

Gold standard in diagnosis and treatment

Super-selective arteriography of the external carotid

 evaluates

collaterals and multiple anastomoses of the Internal maxillary artery

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Management

Sclerosing

agents

(sodium

morrhuate,alcohol

, tetracycline etc

.)



ineffective most of the times

Ligation of the external carotid



not

recommended

Numerous

anastomoses (internal carotid, ophthalmic, vertebral, cervical, and contralateral external carotid) and collateral

vessels

Limits

further

angiography and

future

embolization

Direct trans osseous

puncture

of the vascular bed and

embolization

Embolization

(Onyx

,

cyanoacrylate,

polyvinyl alcohol particles,

Gelfoam

, coils

, collagen)

Pre operative embolization in acute phase then surgery within 48 hours to 2 weeks

Usually multiple

stages

of embolization

for

curative results

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19-month-old female with left lower gingiva bleeding

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Skull AP and Towns views were performed. No demonstrable lytic lesion within the mandible is noted. This is an inappropriate study to evaluate a mandibular lesion.

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MRI and MRA of the head and neck were obtained.

A - B:

Coronal T2 (A) and axial T1 fat suppression images show an

expansile

T1

iso

/T2

hyperintense bony lesion within the left-sided mandible involving body, angle and ramus (orange arrows). Involvement of the left canine, left premolar and left 1st molar teeth is noted. Several flow void signals are noted, best seen on T2 images.C - D: Post contrast T1 fat suppression in coronal (C) and axial (D) images show heterogeneous contrast enhancement and increased signal intensity with in the left masseter and let temporalis muscles.E - F: MIP MRA images of the head and neck vessels show enlargement of the left external carotid artery (blue arrows) supplying this mass (pink arrow) with early draining vein to the left external jugular vein (green arrow).

F

E

D

C

B

A

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Conventional angiogram with left external carotid artery catheterization.

A – B:

There is

a

vascular blush of the mass (green arrow) within the left buccal/maxillary region supplied by branches of the left internal maxillary artery (orange arrows) and left facial artery (blue arrows) with AV shunting and venous drainage into the external jugular vein (pink arrows).C: Post PVA embolization via the left internal maxillary artery, superficial temporal, and left facial arteries with nearly complete disappearance of the vascular blush.

A

C

B

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7-year-old MALE with right lower gingiva mass with intermittent bleeding for a month. Recent history of active bleeding with shock

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Grossly unremarkable Panoramic radiograph of the mandible

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MRI and MRA of the head and neck without and with contrastA-B: Axial T1 fat suppression (A) and T2 fat suppression (B) images show T1/T2 hyperintense expansile lesion within the body of the right-sided mandible (orange arrows). A few signal voids are noted.C-D: Post contrast axial T1 fat suppression (C) and coronal T1 fat suppression (D) images show heterogeneous contrast enhancement within this mass (orange arrows).D-E: Contrasted MRA images show dilation of the right facial vein (blue arrow) and external carotid artery (pink arrows), related to a feeding artery.F: MIP image shows dilation of the right external carotid artery (pink arrow) with no visualized drain vein.

G

F

E

D

C

A

B

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D

C

B

A

Conventional angiogram with right external carotid artery catheterization

A-B:

Lateral and AP images show abnormal vascular blush with arterial supply from

the right facial (orange arrows)

and

right internal maxillary arteries (blue arrows) and early draining vein to the right external jugular vein (pink arrow).C-D: Post embolization images after gelfoam and NBCA injection show complete occlusion of the mandibular AVM.

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12-year-old male with lower gingiva bleeding

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CT head and neck with contrast

A-B:

Axial and coronal CT without contrast at the level of the mandible show

well-defined lytic lesion within the posterior body of the right mandible associated with tooth root resorption (orange arrows).

C-D: Axial post contrast images show avid enhancement within this lesion (blue arrow) associated with enlargement of the right external carotid artery and right facial artery. Findings are suggestive of AVM.

A

B

C

D

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Conventional angiogram with right external carotid artery catheterization

A-D:

AP and lateral images show abnormal vascular blush with arterial supply from the

right

inferior

alveolar (orange arrows)

and

right facial arteries (blue arrows). Drainage to the right facial vein (pink arrow) is noted. There is a large venous pouch in the right mandibular body (green arrow). E-F: Post embolization images with NBCA demonstrate residual venous pouch (green arrow) and vascular blush lesion. Patient was scheduled for second stage embolization within a month.

F

E

D

B

C

A

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Second stage embolization with NBCA

R

esidual

small AVM

was treated with NBCA. Post embolization

angiogram shows marked decreased flow of the AVM and

increased

venous stagnation.

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15-year-old male with vascular mass found on dental procedure

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15-year-old boy with intra-oral vascular mass identified incidentally during a dental procedure. A: Axial CT image shows a lytic lesion within the posterior body of the right mandible (orange arrow).B: Axial T1 post contrast image shows an enhancing vascular mass in the right mandibular body (blue arrow).C: Doppler US demonstrates an AVM in the right mandibular body draining into a dilated varix (green star).D: DSA lateral image from the right external carotid artery injection shows an AVM supplied by branches of the facial and internal maxillary arteries (pink arrow) with venous drainage predominantly to the right external jugular vein.E – F: Post-embolization lateral images of the right external carotid artery injection show approximately 80% occlusion of the mandibular AVM (yellow arrow = residual AVM).

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Conclusion

Vascular

malformations of the mandible are

extremely rare

potentially

life-threatening

conditions presenting with intractable

hemorrhage after tooth

extractions

or

biopsies.

Occur

predominantly during childhood with a variety

of symptoms

including gingival bleeding, bruit, dental loosening, swelling of the soft tissues of the face,

discoloration of the skin and mucosa and

sometime neurosensory deficits.

Think about vascular AVM in case of gingival bleeding/ lesion in the posterior body of the mandible.

Cross-sectional

imaging especially CT and MRI with contrast are useful imaging modalities

for clarifying the

extent of the lesion, the degree of bone

erosion, and

involvement of major

vessels

(feeding arteries and draining veins).

Radiologist

should be able to recognize the imaging patterns to avoid

risky and unnecessary biopsies

and suggest prompt treatment in case of life-threatening hemorrhage or the need for preoperative

treatment with endovascular or percutaneous embolization

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References

Scholl

, Robert J., et al. "Cysts and Cystic Lesions of the Mandible: Clinical and Radiologic-

Histopathologic

Review 1."

Radiographics

19.5 (1999): 1107-1124.

Singh

V

,

Bhardwaj

PK

. Arteriovenous malformation of mandible: Extracorporeal curettage with immediate replantation technique.

Natl

J

Maxillofac

Surg. 2010 Jan-Jun; 1(1): 45–49.

Kiyosue

,

Hiro

, et al. "Treatment of mandibular arteriovenous malformation by

transvenous

embolization: a case report." Head & neck 21.6 (1999): 574-577.

Noreau

,

Gaétan

, Pierre-É. Landry, and

Dany

Morais

. "Arteriovenous malformation of the mandible: review of literature and case history." Journal-Canadian Dental Association 67.11 (2001): 646-651

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