Pediatric Facial Arteriovenous Malformations: Case Report and Overview of the Basics

Aims: Describe the multimodality imaging of a large facial AVM in a child and discuss the treatment options of pediatric facial AVMs
Case Presentation: An 11 year old girl developed spontaneous (no prior trauma) enlargement of her left cheek with bleeding from her mouth when eating hard foods. The bleeding was described as pulsatile red bleeding that stopped spontaneously. On physical exam, she had a palpable pulsatile left buccal AVM; auscultation revealing high-flow through it. MRI demonstrated a 2.7 cm heterogeneous vascular mass arising in the soft tissues of the left cheek with involvement of the anterior wall of the left maxillary sinus with a large tortuous ectatic draining vein. CTA demonstrated a large AVM involving the left face with the nidus along the posterior wall of the left maxillary sinus, markedly enlarged draining veins throughout the left face/cheek and prominence of the pterygoid venous plexus. Left common carotid artery angiogram demonstrated an extensive AVM centered in the left maxilla. Left external carotid artery angiogram demonstrates the AVM receiving supply from the distal left internal maxillary, left facial, and left internal maxillary arteries. Angiography of the left internal maxillary demonstrated a high flow AVM with drainage to the left facial vein. The left internal maxillary artery was embolized using Onyx. The left facial, transverse facial, and internal maxillary arteries were embolized with PVA particles. Following embolization, blood supply to the AVM was substantially reduced. At surgery, the AVM was resected.
Discussion and Conclusion: Head and neck AVMs have a high morbidity as they tend to be clinically silent until manipulation/trauma results in bleeding. Those that bleed have a high incidence of rebleed. Embolization is utilized pre-operatively to decrease bleeding but not as the primary treatment due to potential for developing collaterals. Treatment remains controversial due to the rarity of the lesion, but typically involves a multidisciplinary approach as in our case.