Multimodality Evaluation and Management of a High-Flow Mandibular Arteriovenous Malformation: A Case Report

Purpose: Arteriovenous malformations (AVMs) are congenital vascular malformations that may occur anywhere in the body, the mandible being the most commonly involved site in the head and neck. However, intraosseous mandibular AVMs are still very rare and have been found to be more difficult to characterize and manage than intraosseous AVMs elsewhere in the body because of the complex maxillofacial vascular anatomy. These mostly present as facial deformities or increasing swelling and may result in life-threatening gingival bleeding after dental procedures. Our purpose is to present the case of a high-flow mandibular AVM, discussing the important imaging findings and role of endovascular intervention in the management of this entity.

Materials and Methods: Retrospective analysis of the medical record was performed, as well as evaluation of available imaging.

Results: We present the case of a 15-year-old male patient with no significant past medical history who presented for evaluation of a pulsatile mass in his left mandible and cheek, which he noticed had been increasing in size. Sonographic evaluation of the area of concern revealed a large submandibular high-flow vascular malformation, suspicious for an AVM versus AV fistula. This was further characterized with magnetic resonance angiography, which confirmed a large AVM involving the floor of the mouth and submandibular fossa, as well as an intraosseous component in the left mandible; arterial feeders arising from multiple branches of the left external carotid artery and venous drainage into the left jugular vein were identified. The patient underwent three staged vascular embolizations followed by an en bloc resection of the left mandible with the residual intraosseous component of the vascular malformation.

Conclusions: Given the high potential for morbidity and mortality, it is of utmost importance for radiologists to be able to identify mandibular AVMs, as well as provide adequate imaging recommendations for their evaluation and management. We provide multiple images (ultrasonography, magnetic resonance imaging, computed tomography, angiography) and discuss the main imaging findings. We also discuss management alternatives for mandibular AVMs, particularly the role of endovascular therapy.