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International Journal of Trichology International Journal of Trichology
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CONTINUING MEDICAL EDUCATION
Year : 2022  |  Volume : 14  |  Issue : 4  |  Page : 141-143  

Transient alopecia after embolization of intracranial aneurysm: Case report and review


1 Department of Dermatology, Severo Ochoa University Hospital, Leganés, Madrid, Spain
2 Department of Dermatology, Hospital del Mar-Parc de Salut Mar, Barcelona, Spain

Date of Submission09-Jun-2020
Date of Acceptance29-Oct-2021
Date of Web Publication16-Jul-2022

Correspondence Address:
Jorge Roman-Sainz
Travesía de Téllez 8, 7 R. CP: 28007, Madrid
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijt.ijt_94_20

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How to cite this article:
Roman-Sainz J, Silvestre-Torner N, Lobato-Berezo A, Imbernón-Moya A. Transient alopecia after embolization of intracranial aneurysm: Case report and review. Int J Trichol 2022;14:141-3

How to cite this URL:
Roman-Sainz J, Silvestre-Torner N, Lobato-Berezo A, Imbernón-Moya A. Transient alopecia after embolization of intracranial aneurysm: Case report and review. Int J Trichol [serial online] 2022 [cited 2022 Aug 14];14:141-3. Available from: https://www.ijtrichology.com/text.asp?2022/14/4/141/351246



Endovascular interventional procedures are widely used for intracranial arterial pathologies treatment. They also require realization of fluoroscopy, a technique that relies on the properties of X-rays to obtain real-time images.[1] Many cases of transient alopecia after this procedure have been reported.

A previously healthy, 45-year-old male was admitted with an intracranial hemorrhage after a spontaneous rupture of an aneurysm in the anterior communicating artery. Two embolization procedures were required. Two weeks after the last one, he experienced a partial hair loss, comprising the left temporoparietal scalp region. A 7.5 cm-sized alopecia plaque was observed, which presented with striking angular edges with rectangular morphology [Figure 1]a. Pull test was positive. Trichoscopy showed black dots, as well as short vellus hairs [Figure 1]b. Lack of peladic hairs ruled out alopecia areata. Skin biopsy revealed multiple pilosebaceous units with minimal perifollicular lymphocitic infiltrate, as well as obliterated follicles without signs of fibrosis or lichenoid reaction. After 2 months, the patient showed complete hair regrowth and no treatment was prescribed.
Figure 1: (a) Alopecia areata in the patient's left temporoparietal region. Note the angular edges which give it a perfectly square contour. (b) Trichoscopy performed on the edge of the alopecia area. Black dots can be observed, as well as short vellus hair

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Transient radiation alopecia (TRA) is an adverse effect, which usually appears with accumulated doses between 3 and 6 Gy. Greater doses than 6 Gy may cause scarring alopecia.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] This is caused by the simultaneous entry of multiple follicular cells in catagen phase. The usual dose of radiation produced by a fluoroscopy X-ray unit is usually between 0.02 and 0.05 Gy/min, which increases with the sequential use of other procedures that use radiation.[1]

Fifty-eight cases of TRA have been reported after intracranial arterial embolization, being more frequent in women, with a ratio of 1.41:1 [Table 1]. The age varies from 13 to 70 years (mean age: 42.87), but most of the patients described were between 30 and 50 years. Patients report sudden hair loss in a short period of time, producing plaques of alopecia whose size and shape vary depending on the model of the device used. These areas show characteristic angular edges, which along with the medical history is essential for the differential diagnosis with alopecia areata.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10]
Table 1: Characteristics of patients with transient radiation alopecia reported in the literature since 1994

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The cumulative radiation dose was in most cases greater than 3 Gy, with 92% of cases ranging between 3 and 6 Gy. Only one patient developed alopecia with doses below 3 Gy,[1] and four cases received doses above 6 Gy.[1] Only one case of scarring TRA has been reported.[8] In the case of our patient, we do not know the exact dose of radiation received, but a total dose greater than 3 Gy was estimated due to the need of a second embolization.

In trichoscopy, the most common findings include black dots and yellow dots, followed by short, vellus hairs. Broken hairs and white dots are less common.[8],[10] These findings can be observed in alopecia areata. However, exclamation hairs are often seen in the latter, a finding that is not present in TRA.

Histological findings were described in 11 patients,[8],[9],[10] and they included anagen or catagen follicles lacking inflammatory infiltrate or scar tissue. Differential diagnosis should be made mainly with alopecia areata, in which a characteristic peri/intrabulbar lymphocytic inflammatory infiltrate with a “honey-comb” image is usually observed.

Time from the embolization procedure to the onset of alopecia ranges from 1 to 8 weeks, occurring in 93% of cases between the 2nd and the 4th week. The symptoms resolve spontaneously between 2 and 6 months, with complete regrowth with terminal hairs without color or thickness alterations, except in one case where the hair presented a more grayish hue, and in another described case, the patient presented scarring alopecia without repopulation.[8] In some cases, superficial cryotherapy, topical corticosteroids, topical minoxidil, and/or intralesional triamcinolone were applied, without significant differences in terms of evolution compared to the rest of untreated patients.[9],[10]

In conclusion, TRA is generally a transient condition that resolves without the need of treatment. Given the increase of such interventional procedures in recent years, it is important to know this entity and differentiate it mainly from alopecia areata. It should also be considered adding this side effect to the informed consent of such interventions. For a correct diagnosis, it is essential to carry out an adequate clinical history oriented to interventional procedures undergone by the patient and should be suspected when facing an area of alopecia with sharp and angular edges.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Freysz M, Mertz L, Lipsker D. Temporary localized alopecia following neuroradiological procedures: 18 cases. Ann Dermatol Venereol 2014;141:15-22.  Back to cited text no. 1
    
2.
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. 2
    
3.
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. 3
    
4.
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. 4
    
5.
Verma S, Srinivas C, Thomas M. Radiation-induced temporary alopecia after embolization of cerebral aneurysm. Indian J Dermatol 2014;59:633.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Vaccaro M, Guarneri F, Brianti P, Cannavò SP. Temporary radiation-induced alopecia after embolization of a cerebral arteriovenous malformation. Clin Exp Dermatol 2015;40:88-90.  Back to cited text no. 6
    
7.
Vazquez A, Shukla PA, Choudhry OJ, Gandhi CD, Liu JK, Eloy JA. Geometric alopecia after preoperative angioembolization of juvenile nasopharyngeal angiofibroma. Allergy Rhinol (Providence) 2013;4:e21-4.  Back to cited text no. 7
    
8.
Cho S, Choi MJ, Lee JS, Zheng Z, Kim DY. Dermoscopic findings in radiation-induced alopecia after angioembolization. Dermatology 2014;229:141-5.  Back to cited text no. 8
    
9.
Lee H, Lee S, Lee YB, Lee WS. Radiation-induced rectangular alopecia after endovascular embolization of cerebral aneurysms: The necessity of a comprehensive study on its incidence and critical radiation doses. Ann Dermatol 2019;31:S24-6.  Back to cited text no. 9
    
10.
Seol JE, Kim DH, Park SH, Cho GJ, Kim H. Three cases of radiation-induced temporary alopecia with hair microscopic examination: “Coudability hair” might not be specific for alopecia areata. Int J Trichology 2018;10:40-3.  Back to cited text no. 10
    


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