Correspondence Address:
Dr. Ashutosh Kaushal
Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi
India

Full Text



Sir,

Alopecia is a common side effect of radiation therapy in cancer patients; however, alopecia following fluoroscopy-guided endovascular procedures was not common entity until recently due to the increasing number of such procedures. We report a case of localized scalp alopecia after embolization of orbital arteriovenous malformation (AVM). A 15-year-old male, a known case of residual right orbital AVM, came for endovascular embolization. Apart from complaints associated with AVM, he had a sharply demarcated alopecia patch (7 cm × 5 cm) on the scalp in the occipital area [Figure 1]. It appeared following endovascular embolization of AVM done 4 weeks back. The total duration of procedure was 7 h, and the perioperative course was uneventful. The patch was skin colored, with no scarring, scaling, itching, erythema, or dermatitis.{Figure 1}

Fluoroscopic-guided endovascular procedures are frequently performed nowadays owing to lesser invasiveness, duration of procedure, and complications leading to reduced morbidity and mortality. The radiation dose delivered in endovascular fluoroscopy procedures depends on type and duration of the procedure. Radiation dose of 3–6 gray results in temporary epilation.[1] The potential mechanisms of alopecia after fluoroscopy-guided procedure include pressure-induced alopecia after lying for prolonged duration or direct blunt trauma, impairment of the external carotid blood supply of the scalp due to embolus, luminal fibrosis due to radiation,[1] and radiation-induced alopecia. In this patient, superficial temporal and occipital arterial pulsation was good ruling out inadequate blood supply. The absence of tenderness, swelling, or crusting ruled out pressure-induced alopecia. Asymptomatic, geometric-shaped nonscarring alopecic patch in occipital, parietal, and temporal scalp limited to radiation area is characteristic of radiation-induced alopecia. The average dose of radiation following fluoroscopic-guided procedure depends on type and duration of procedure.

Although the exact incidence of alopecia after fluoroscopy is not known, in one study in patients with cerebral aneurysm treated by embolization under fluoroscopic guidance, 9 patients (6.7%) developed alopecia.[2] Actively dividing matrix cells in anagen follicles are radiation sensitive. Hair loss occurs due to premature entry of some anagen hair follicles into catagen and then into telogen phase.[1] Under microscope, hair looks like bayonet because distal hair shaft becomes dystrophic with a rapidly tapering formation. Hair loss generally occurs within 2–5 weeks following radiation exposure and hair regrows spontaneously within 2–6 months.[3] Radiation dose, duration, gap between irradiations, area of irradiated surface, irradiation angle, and factors such as age, smoking, malnutrition, connective tissue diseases, tissue oxygenation, capillary density, hormonal status, genetic, ethnicity, and diabetes mellitus determine the occurrence and severity of radiation-induced temporary alopecia.[4] Antineoplastic drugs are reported to augment radiosensitivity.[4] However, no such risk is applicable in benign disease like AVM. Awareness, online monitoring of fluoroscopy time, fluoroscopic dose rates, and control of radiation exposure to the smallest amount required to complete the procedure help in limiting radiation dose and its consequences.[5] Radiation-induced alopecia is benign and self-limiting entity, common after radiotherapy; however, it is less commonly seen after fluoroscopy-guided interventional procedures. Scalp hair is important to a person's self-image, especially in a young patient, so patients should be well informed of this less commonly expected side effect of fluoroscopy-guided procedures.

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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.

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Conflicts of interest

There are no conflicts of interest.

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