Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

FOREWORD
Year
: 2003  |  Volume : 13  |  Issue : 3  |  Page : 257--260

Case report : Vascular lesion of face


SB Patel, A Desai, S Desai, RR Vyas, HC Soni 
 Department of Radio-diagnosis, Gujarat Cancer and Research Institute Asarwa, Ahmedabad-380016, India

Correspondence Address:
S B Patel
Department of Radio-diagnosis, Gujarat Cancer and Research Institute Asarwa, Ahmedabad-380016
India




How to cite this article:
Patel S B, Desai A, Desai S, Vyas R R, Soni H C. Case report : Vascular lesion of face.Indian J Radiol Imaging 2003;13:257-260


How to cite this URL:
Patel S B, Desai A, Desai S, Vyas R R, Soni H C. Case report : Vascular lesion of face. Indian J Radiol Imaging [serial online] 2003 [cited 2019 Jun 25 ];13:257-260
Available from: http://www.ijri.org/text.asp?2003/13/3/257/28693


Full Text

 Introduction



Vascular lesions of the face are not very common. These lesions are a perplexing group of problems that over the years have generated a significant debate and confusion as regards their terminology and classification. Descriptive anatomic, pathologic and embryologic classification scheme have been devised however generally have not offered the clinician significant guidance for treatment. The classification developed by Mulliken and Glowaki in 1982 is based on the cellular kinetics of anomalous vessels, providing a diagnostic and therapeutic approach based on the biologic behavior of the lesion [1],[2]. In this classification, two entities exist: 1) Hemangiomas and 2) Vascular malformation.

Case History 1 :

Twenty years old man presented with complaints of swelling over the left side of the face for seven to eight years. Patient had no history of pain, fever, pus discharge or sinus. On examination the mass was soft and showed a bluish tinge. Digital substraction Angiography was performed it showed an elongated left facial artery entering into a soft tissue swelling over the lip with phlebolith. No evidence of enlargement of any external carotid artery feeders / Arterio venous malformation. Vertebro basilar artery, right common carotid artery, left Common carotid artery and both internal carotid arteries appear normal. No evidence of any hypertrophy, tumor blush or arteriovenous malformation. There is presence of phlebolith in the soft tissue of cheek with dilated enhancing vessels seen in delayed contrast CT coronal cuts, which is suggestive of venous hemangioma.

Findings suggest diagnosis of hemangioma with elongated left facial artery.

Case History 2 :

Seventeen year old woman presented with complaint of swelling over left lip and face for six to seven years, which gradually increased in size, swelling over medial aspect of orbits for three to four years. Patient had no history of pain, fever, pus discharge or sinus. On examination the mass was soft and shows reddish tinge. Digital substraction Angiography was performed and it shows large dilated tortuous, serpiginous vessels seen in arterial phase without intervening capillaries involving lip, left sided face and medial aspects of orbit with feeders from both right and left External carotid arteries. Feeders from left External carotid artery are facial artery, lingual artery, internal maxillary artery, superficial temporal artery and from right external carotid artery are facial artery, internal maxillary artery and superficial temporal artery. Drainage is rapid through external jugular vein & internal jugular vein. Feeders from left side are more prominent and hypertrophied than on the right side.

Findings suggest diagnosis of Arteriovenous malformation.

 Discussion



Hemangiomas are the most common cutaneous tumor of Infancy and are characterized by rapid growth and proliferation. Hemangioma undergo a slow and spontaneous involution with subsequent regression within 5 to 7 years Histologically hemangiomas are characterized by endothelial hypercellularity and increased mitotic activity during the proliferation phase and by fibrosis and fat deposition during the involution phase [2]. Unlike hemangiomas, malformation has a normal rate of endothelial cell turnover, enlarge proportionately with the growth of the child, and do not undergo spontaneous involution [2].

Malformations are further subdivided based on their cellular composition into either slow flow (capillary, venous, lymphatic or mixed) or fast flow (arteriole, arterio venous, fistulae or shunt) subtype. The term cavernous is used to describe large channel venous or lymphatic malformation consisting of dilated thin walled, endothelial lined sinuses engorged with red blood cell.

Imaging studies should be used for diagnosis, Ultrasonography using color doppler flow analysis can confirm fast flow anomalies [3]. MRI with or without intravenous gadolinium can be used to define the lesion in relation to surrounding tissues. Recently, magnetic resonance Angiography (MRA) has been combined with MRI to provide detailed information regarding Flow characteristics and the extent of local tissue involvement [4]. Invasive Angiography is used for diagnosis but can be useful before extensive surgery for embolization. Plain radiographs are of little value but can show calcified phleboliths or cortical erosion of bone in approximately 6% of cases [5].

Hormonal factors are also implicated in the enlargement of vascular malformation. Using current definition, vascular malformation occurs more commonly in female patients with female to male ratio of 1.5 : 1. Older studies not distinguishing malformation from hemangiomas also found a higher incidence of vascular anomalies in female patients of approximately 2:1[5],[6].

Management of vascular lesions is guided by location, flow characteristics, symptoms, functional disability and cosmetic deformity [7].

Treatment of childhood hemangiomas consists mainly of observation until involution occurs. Non-surgical treatment, such as injection of sclerosing agent, radiation or cryotherapy has showed poor results for subcutaneous hemangiomas. Cryotherapy and argon laser therapy may be considered when the lesion is intradermal but can result in a broad fibrous white scar.

Management of symptomatic vascular malformation consists primarily of surgical excision. Conservative treatment with rest, compression and analgesics can be attempted but is unlikely to result in complete resolution, indication for surgical excision include pain, functional impairment, progressive growth, compressive neuropathy or problems caused by mass effect. The risk of recurrence after surgical excision increased with the presence of arteriovenous shunt, local tissue infiltration and lesions greater than 2cm [8]. Selective arterial embolization might be helpful in fast flow anomalies before surgical resection.

References

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4Disa JJ Chung KC, Gellad FE, Bickel KD Wilgis EF. Efficacy of magnetic resonance Angiography in the evaluation of vascular malformation plast. Reconstr. Surg 1999 ; 99 ; 136-44.
5Palmieri TJ . Subcutaneous hemangioma of the Face . J Hand Surg 1983 ; 8 : 201-4.
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