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Year : 2013  |  Volume : 5  |  Issue : 4  |  Page : 201-203  

Square alopecia: A new type of transient alopecia of the scalp following fluoroscopically endovascular embolization

1 Department of Dermatology, Hospital Clinic, University of Barcelona, Barcelona, Spain
2 Department of Interventional Neuroradiology, Hospital Clinic, University of Barcelona, Barcelona, Spain

Date of Web Publication11-Apr-2014

Correspondence Address:
Sebastian Podlipnik
Department of Dermatology, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-7753.130406

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Endovascular interventional procedures are the first choice of treatment for many vascular intracranial lesions, especially those with complex anatomy. These procedures may cause numerous skin lesions depending on the dose of radiation to which patients have been exposed. In this report, we presented a case of a 38-year-old man who developed a square plaque of alopecia in the occipital area after two selective embolization of a left posterior parasagittal arteriovenous malformation. The alopecia was transient and the hair grew up 2 months later after the last procedure. This case illustrates one of the effects of radiation on the scalp and expands our knowledge about the clinical manifestation of this transient disease.

Keywords: Alopecia, arteriovenous malformation, fluoroscopically endovascular procedure, radiation-induced dermatitis

How to cite this article:
Podlipnik S, Giavedoni P, San-Román L, Ferrando J. Square alopecia: A new type of transient alopecia of the scalp following fluoroscopically endovascular embolization. Int J Trichol 2013;5:201-3

How to cite this URL:
Podlipnik S, Giavedoni P, San-Román L, Ferrando J. Square alopecia: A new type of transient alopecia of the scalp following fluoroscopically endovascular embolization. Int J Trichol [serial online] 2013 [cited 2023 Jun 6];5:201-3. Available from: https://www.ijtrichology.com/text.asp?2013/5/4/201/130406

   Introduction Top

Endovascular interventional procedures of intracranial circulation have increased significantly over the past 20 years, because they can treat serious diseases with a significant decrease in morbidity and mortality. These procedures are often associated with long and recurrent periods of fluoroscopy that may cause serious skin lesions associated with radiation. [1],[2] In this study, we report a case of a patient who developed a square shaped alopecia after an endovascular embolization procedure for arteriovenous malformation (AVM).

   Case Report Top

The case we present here is about a 38-year-old man who came to the emergency room in February 2013, due to nausea and diplopia of sudden onset, 1 day prior to admission. Physical examination revealed a limitation of ocular supraversion movements and bilateral absence of pupillary light reflex, consistent with dorsal midbrain syndrome. The blood analysis and blood cell count results were strictly normal. A CT scan showed a left dorsal midbrain hematoma with ventricular hemorrhage and incipient signs of hydrocephalus. Subsequently an intracranial arteriography confirmed the presence of a left posterior parasagittal AVM with contributions from posterior choroidal artery branches [Figure 1]. Endovascular treatment was performed with selective embolization with Glubran ® 20% without any complications. In May 2013, an angiographic control identified remains of the malformation, with bilateral posteromedial choroidal afferents. A new selective embolization was performed in July 2013, which achieved a complete devascularization of the AVM with excellent angiographic results.
Figure 1: Angiogram (anteroposterior view) demonstrate a left posterior parasagittal arteriovenous malformation with contributions from posterior choroidal artery branches (black arrow)

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A month later, he presented to the Dermatology Department for hair loss localized in the occipital region of the head. Physical examination showed an alopecic square plaque of 5 cm × 5 cm with almost total hair loss, but without signs of inflammation [Figure 2]. Dermoscopy exam showed no exclamation mark hairs and bilateral superficial arterial pulses were normal.
Figure 2: Sharply defi ned square alopecia in the occipital region with almost total hair loss and no signs of infl ammation. The lesion occurred 4 weeks after the last endovascular procedure

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In total, the patient was exposed to four angiographic procedures, two of them with endovascular therapy. The total radiation exposure time was approximately 150-200 min and the absorbed radiation dose after the last session was estimated at more than 4 Gy. Radiation-induced transient alopecia diagnosis was established and there was no need to start treatment. The hair grew back 2 months after the last procedure.

   Discussion Top

After an interval of more than half a century, reports of fluoroscopically induced skin lesions reappeared in the literature in the 1990s. These reports coincide with the introduction of fluoroscopically guided interventional procedures in the clinical arsenal. [2] Although the effects of radiation therapy are well-documented, the skin effects of radiation by fluoroscopically endovascular procedures are scarce. [3] In 1994, Huda et al. published the first case of alopecia secondary to an endovascular procedure guided by fluoroscopy, [4] since then there have been few reports in dermatology journals. [5],[6],[7],[8],[9],[10],[11],[12],[13]

The scalp is very resistant to radiation exposure, but paradoxically alopecia presents with lower doses of radiation than the rest of the body. [2] This radiodermatitis has been attributed to the high sensitivity of hair follicles to radiation in the anagen phase that particularly affects rapidly dividing cells of the follicular matrix. At low doses (2-5 Gy), mild dermatitis may occur and later evolve into a temporary hair loss that manifests as geographical pattern alopecia. In medium doses (5-10 Gy) a more prolonged erythema and permanent partial alopecia appear. At high doses (10-15 Gy) permanent scarring alopecia and late radiation skin changes such as skin induration, telangiectasia and skin fragility are produced. [2],[7] Other factors that may favor the development of alopecia are: The total time of the procedure, residual effects of previous radiation procedures and some patient biological factors (age, smoking, malnutrition, tissue oxygenation, capillary density, hormonal status, genetic factors, lesion location, and ethnicity). [2],[14]

Alopecia is usually transient. It starts at 2-5 weeks after the endovascular procedures and has a good prognosis of hair reappearing from 2 to 6 months later. [6] The main differential diagnoses are pressure-induced (postoperative) alopecia secondary to hypoxia, which occurs in areas of prolonged pressure on the scalp during operative procedures, and alopecia areata, especially with an ophiasis pattern. [8],[15]

   Conclusion Top

Transient radiation alopecia is a difficult diagnosis and often is misdiagnosed by dermatologists. It does not require specific treatment, and most patients recover hair in few months; therefore, the most important thing is to give adequate information to the patient about this self-limiting process.

   References Top

1.Nannapaneni R, Behari S, Mendelow D, Gholkar A. Temporary alopecia after subarachnoid haemorrhage. J Clin Neurosci 2007;14:157-61.  Back to cited text no. 1
2.Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: A review of radiation effects on patients' skin and hair. Radiology 2010;254:326-41.  Back to cited text no. 2
3.Thorat JD, Hwang PY. Peculiar geometric alopecia and trigeminal nerve dysfunction in a patient after Guglielmi detachable coil embolization of a ruptured aneurysm. J Stroke Cerebrovasc Dis 2007;16:40-2.  Back to cited text no. 3
4.Huda W, Peters KR. Radiation-induced temporary epilation after a neuroradiologically guided embolization procedure. Radiology 1994;193:642-4.  Back to cited text no. 4
5.Garnacho GM, Amorrich MV, Salido R, Espejo J. A case of transient rectangular alopecia after aneurysm embolization. Actas Dermosifiliogr 2009;100:909-10.  Back to cited text no. 5
6.López Aventín D, Gil I, López González DM, Pujol RM. Chronic scalp ulceration as a late complication of fluoroscopically guided cerebral aneurysm embolization. Dermatology 2012;224:198-203.  Back to cited text no. 6
7.D'incan M, Roger H, Gabrillargues J, Mansard S, Parent S, Chazal J, et al. Radiation-induced temporary hair loss after endovascular embolization of the cerebral arteries: Six cases. Ann Dermatol Venereol 2002;129:703-6.  Back to cited text no. 7
8.Tosti A, Piraccini BM, Alagna G. Temporary hair loss simulating alopecia areata after endovascular surgery of cerebral arteriovenous malformations: A report of 3 cases. Arch Dermatol 1999;135:1555-6.  Back to cited text no. 8
9.Krasovec M, Trüeb RM. Temporary roentgen epilation after embolization of a cerebral arteriovenous malformation. Hautarzt 1998;49:307-9.  Back to cited text no. 9
10.Marti N, Lopez V, Pereda C, Martin JM, Montesinos E, Jorda E. Radiation-induced temporary alopecia after embolization of cerebral aneurysms. Dermatol Online J 2008;14:19.  Back to cited text no. 10
11.Dandurand M, Huet P, Guillot B. Secondary radiodermatitis caused by endovascular explorations: 5 cases. Ann Dermatol Venereol 1999;126:413-7.  Back to cited text no. 11
12.Lee WS, Lee SW, Lee S, Lee JW. Postoperative alopecia in five patients after treatment of aneurysm rupture with a Guglielmi detachable coil: Pressure alopecia, radiation induced, or both? J Dermatol 2004;31:848-51.  Back to cited text no. 12
13.López V, López I, Ricart JM. Temporary alopecia after embolization of an arteriovenous malformation. Dermatol Online J 2012;18:14.  Back to cited text no. 13
14.Wen CS, Lin SM, Chen Y, Chen JC, Wang YH, Tseng SH. Radiation-induced temporary alopecia after embolization of cerebral arteriovenous malformations. Clin Neurol Neurosurg 2003;105:215-7.  Back to cited text no. 14
15.Davies KE, Yesudian P. Pressure alopecia. Int J Trichology 2012;4:64-8.  Back to cited text no. 15


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