Case Report

Peculiar Geometric Alopecia and Trigeminal Nerve
Dysfunction in a Patient After Guglielmi Detachable Coil
Embolization of a Ruptured Aneurysm
Jayant Daniel Thorat, MCh, and Peter Y. Hwang, FRACS

Neuroendovascular treatment is increasingly being used for treatment of intracranial aneurysms. Postradiation alopecia, commonly seen weeks after radiation for
other diseases such as brain tumors, is rarely reported after neuroendovascular
procedures for benign lesions because of their delayed manifestations. Although
the morbidity and mortality is less compared with surgery, adverse effects related
to radiation are probably understated, underreported, and/or often attributed to
prolonged bed rest, heparinization, or poor nutrition. We present a case with a
delayed onset of a graphic but peculiar geometric alopecia associated with trigeminal nerve pattern dysfunction, which was related to the fluoroscopic radiation for
coil embolization of an anterior communicating artery aneurysm. Key Words:
Radiation injury—trigeminal nerve dysfunction—alopecia—fluoroscopy—interventional radiology— coil embolization.
© 2007 by National Stroke Association

Case Report
A 34-year-old man, who was right-handed, a nonsmoker, and a nonalcoholic, presented with acute headache and vertiginous giddiness for a day. He had no
history of trauma or any other constitutional symptoms.
Results of his general physical examinations were normal
but with mild neck rigidity. His cranial nerves were
normal and he had no neurologic deficit. He had no
history of radiation, alopecia, or dermatitis, or any family
history of male pattern baldness.

Investigations
A plain computed tomography scan was promptly
performed, revealing diffuse basal and anterior interFrom the Department of Neurosurgery, National Neuroscience
Institute, Tan Tock Seng Hospital Campus, Singapore.
Received September 16, 2006; revised October 22, 2006; accepted
October 24, 2006.
Address correspondence to Jayant Daniel Thorat, MCh, Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan
Tock Seng, Tan Tock Seng Hospital Campus, Singapore 308433.
E-mail: cereglobe@yahoo.co.in.
1052-3057/$—see front matter
© 2007 by National Stroke Association
doi:10.1016/j.jstrokecerebrovasdis.2006.10.003

40

hemispheric subarachnoid hemorrhage Hunt and Hess
grade 1 without intraventricular extension.

Intervention
Four-vessel digital subtraction angiography, carried
out the same evening, displayed a 2.5-mm diameter anterior communicating artery aneurysm measuring 4 mm
in length, on a dominant left anterior cerebral artery
(Fig 1). The patient underwent Guglielmi detachable coiling (Target Therapeutics, Freemont, CA) under general
anesthesia an hour later. A shielded right anterior oblique
(RAO) view, acquired by 33-degree caudal tilt with a
13-degree rotation to the right side, best delineated the
aneurysm (Fig 1). The aneurysm ruptured, for which a
second coil was inserted with successful occlusion of the
aneurysm. This total procedure lasted 150 minutes with
the specific RAO view accounting for approximately 105
minutes. There were a total of 80 acquisitions for RAO
view alone. An external ventricular drain was inserted
postoperatively. A check angiography, on the next day,
confirmed complete aneurysm occlusion. At 7 days postcoiling, the patient recovered without any neurologic
sequelae and was discharged on nimodipine for a week
and phenytoin for a month.

Journal of Stroke and Cerebrovascular Diseases, Vol. 16, No. 1 (January-February), 2007: pp 40-42

PECULIAR GEOMETRIC ALOPECIA AND TRIGEMINAL NERVE DYSFUNCTION POSTEMBOLIZATION

Figure 1. RAO view (caudal 33 degrees and RAO tilt of 13 degrees) with
Gugliellmi detachable coil in partially occluded sac.

41

sessions separated by 3 days). Imaging had included 110
minutes of fluoroscopy and 46 digital subtraction angiography acquisitions. Wen et al,3 who had reported temporary alopecia after embolization of cerebral arteriovenous
malformations, also identified other factors affecting the
skin besides radiation dose, such as dose rate, fractionation, size of exposed area and its site, and biological
factors (age, oxygen status, capillary density, hormonal
status, genetic factors, and ethnic differences). Lee et al6
also reported alopecia in 5 patients after Guglielmi detachable coiling and theorized that it was probably
caused by both pressure effect and radiation induced.
Their cases were characterized by an unusual distribution
of alopecia (temporal scalp and the occipital scalp), short
duration of procedure (total time of anesthesia was relatively short, 2-3 hours), and radiation exposure (ionizing
radiation (⬎2 Gy). Jung et al7 reported 9 cases (6.7%) with
alopecia (temporoparietal or occipital regions) in 135
patients treated for 161 aneurysm by coiling. Our patient
has similarities to these reports in that the fluoroscopy
time was prolonged because of intraoperative rupture.
However, in our case, the shape was peculiar and was
associated with trigeminal nerve area dysfunction. Although pulsed fluoroscopy was used, only one predominant view was used for the procedure. The temporary
hyperoxia, possibly induced from the patient being ventilated under anaesthesia for the procedure, may have

At 6-week follow-up he presented with sharply delineated rectangular alopecia over the left parieto-occipital
region (Fig 2). The capillary telangiectasia of the thinned
out skin were visible. The size and rectangular shape (8 ⫻
10 cm) were congruent to the RAO window used for coil
embolization. The epilation had started 2 weeks after
discharge. There was diminished sensation in the patch
of alopecia but no redness. The patient also had burning
pain in the left jaw and numbness in the left infraorbital
region that, on clinical examination, revealed mild sensory loss in distribution of the second and third divisions
of the trigeminal nerve. The patient had no other neurologic deficits. At 6 months, alopecia and trigeminal paresthesias persisted.

Discussion
Alopecia after head and neck radiotherapy has been
well reported, but there are few reports after neuroendovascular treatment.1,2 However, none of these had described the peculiar shape and extent as in our case.
Temporary hair loss is a peculiar form of radiodermatitis
occurring postglue embolization of arteriovenous malformations and some after coil embolization.3,4 Huda and
Peters5 reported epilation in the right occipital region of
a 34-year-old woman, approximately 5 weeks after embolization of a left paraorbital arteriovenous malformation guided with a biplane radiograph system (in two

Figure 2. Sharply defined left paramedian parieto-occipital rectangular
complete alopecia.

THORAT AND HWANG

42

compounded the radiation damage by sensitizing the
vascular scalp.3 The third factor highlighted by our patient is the onset of paresthesias possibly caused by
ipsilateral trigeminal nerve damage within the radiation
field. The site and size of alopecia and subsequent trigeminal nerve dysfunction was consistent with use of
collimated radiation beam during fluoroscopy.
Radiation side effects suddenly rise with increase in
dose and duration beyond a certain threshold.8 The estimated skin entrance dose in our patient was approximately 2 Gy. Some have reported transient skin injury to
occur at higher threshold levels of peak entrance skin
doses.9 On September 15, 1995, the Food and Drug Administration (FDA)10 recommended that the facility
record in the patient’s medical record information regarding absorbed dose to the skin for any procedure with
the potential for a skin dose approaching or exceeding
some threshold dose for injury. The FDA suggests a
threshold absorbed dose in skin of 1 Gy.10 Certain equipment-related factors such as radiation leak, defective
radiograph collimation, and insufficient filtration should
be looked for and prevented by a regular quality check,
which, in our institution, is done daily and was ruled out
as a cause. The radiation damage to the DNA of hair
follicular cells may also suggest likelihood of damage to
neuronal elements, making a case for much needed longterm follow-up for radiation side effects.
Although, at our institute, use of lead goggles and
thyroid protection device is routine, exposure risks to
limbs cannot be neglected.11 The radiation exposure to
the operator (especially left side) may also be significant
in such cases and may exceed the limits set by The
International Commission on Radiological Protection.
This aspect deserves special attention from female operators of childbearing age.11 Newer units now include
timers that buzz at 5-minute intervals and have limits on
radiation output.12 Dose reduction is possible with realtime dose monitoring, techniques of extra beam filtering,
selection of lower frame rates, pulse progressive fluoroscopy with freeze frame imaging, and use of different
gantry settings to distribute dose over a different area.13

Conclusions
Prolonged exposure in any single view during neuroendovascular procedures can lead to significant radiation-related side effects and risks increases with intraoperative rupture and prolonged procedure time. Radiation
effects on follow-up should be looked for and their reporting is encouraged. Where procedures are likely to be

prolonged or complex, dose-reducing techniques described above should be used and operators should routinely wear full protective gear.
The authors thank the staff and technicians of the neuroradiology department for their help in providing procedural
information and assistance.

References
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