Radiation-induced alopecia is very rare in neurointerventional surgery due to limited radiation dose. Furthermore, no case referred to the reversible hair loss after angioplasty rather than endovascular embolization. A 54-year-old man with diabetes manifested a sign of alopecia after an endovascular stenting for symptomatic basilar artery stenosis. The topography of hair loss patch was in a shape of a rectangle, and it recovered literally in 6 months, without any treatment. The reduction of exposure of patients to radiation during fluoroscopically directed interventional procedures should be performed as possible. Speculatively, metabolic abnormalities such as diabetes and obesity may be considered as an underlying risk that induces skin manifestation in a process of exposure to radiation.
Temporary alopecia after the cerebral endovascular procedure for arteriovenous malformation and aneurysms has been documented [1,2,3,4], whilethe similar skin manifestation after stenting angioplasty was rarely reported because of the less angiographic time to patients. Among the many skin structures, the hair follicle is more sensitive structure to radiation. Potential skin injuries caused by radiation are related to either accumulative skin dose or peak skin dose . Once the hair loss occurs at lower doses of exposure of radiation, it should be carefully checked for other combined factors that can cause skin damage. We describe a patient who underwent recoverable hair loss in occipital area after an endovascular angioplasty, as an atypical presentation of stenting of symptomatic basilar artery (BA) stenosis, which could be mingled with another etiological factor.
A 54-year-old man (a farmer), with paroxysmal dizziness and left lower limb weakness for 2 weeks, arrived to our outpatient clinic after magnetic resonance angiography evidence of severe BA stenosis. The onset of symptoms occurred without convulsion, headache, and visual abnormality, and it was relieved spontaneously in several minutes. The neopathy, however, remained unresponsive after administration of aspirin from primary care physician for 2 weeks. The patient’s past medical history included allergies to alcohol and sulfonamide drugs, 20 pack/year history of smoking, hypertension managed by nifedipine for 20 years, and type 2 diabetes managed by dimethyl since the diagnosis was made 3 months ago. Family history is as follows: the father died of subarachnoid hemorrhage and mother died of stroke. The initial physical examination revealed the following: body mass index 25.5, blood pressure 140/80 mmHg, conscious, fluency of speech, normal cranial nerve examination, normal limb muscle strength, negative pathological signs, no ataxia, and no positive findings on the cardiopulmonary and abdominal examinations. No abnormal findings were observed on electroencephalogram, chest X-ray or electrocardiogram, and in the laboratory test of blood routine, erythrocyte sedimentation rate, C-reactive protein, agglutination, liver function, renal function, glucose, lipids, myocardial enzymes, electrolytes, homocysteine, as well as urine and fecal routine.
As an initial diagnosis, transient ischemic attack (TIA) (probable atherosclerosis of the BA system) was considered; appropriate treatments included clopidogrel and aspirin for antiplatelet aggregation and atorvastatin for plaque stabilization. Since the episodic symptoms remained unsolved after 5 days of treatment, the patient was scheduled for an angioplasty of BA. In the cath lab, systemic unfractionated heparin was administered to achieve heparinization during the procedure. The original cerebral angiography showed 70% stenosis in the inferior segment of BA. Under general anesthesia, an inflation with a 2 × 9 mm balloon (Boston Scientific, USA) was performed progressively at the maximum pressure of 6 atm, with optimal angiographic result. Subsequently, a Solitaire stent 4 × 15 mm (EV3, USA) was planted with good distal blood flow and acceptably residual stenosis (20%). The total time of operation was 1.5 h, while the accumulative dose of radiation was 1.5 Gy approximately.
The patient’s complaints of paroxysmal dizziness and limb weakness disappeared after the operation. And his postoperative clinical course was uneventful until a circumscribed hair loss was observed in the 3rd week after surgery. As processing of differential diagnosis, hereditary hair loss, discoid lupus, other autoimmune diseases, thyroid dysfunction, iron deficiency anemia, syphilis infection, and suspicious drug exposure were excluded. Postoperative administration of clopidogrel had been dismissed after a dermatological consultation; however, aspirin, atorvastatin, and medications for hypertension and diabetes were administered unremittingly. Successively, a square alopecia patch confined to the occipital area presented in 11th postoperative week (Fig. 1). Hair regrew in the lesion area happened, and the whole recovery was confirmed at the 6-month follow-up.
Discussion and Conclusion
The patient described in our case had significant stroke risk factors and uncontrollable transient ischemic attacks, even if dual antiplatelet and statin were administered. Despite the controversy, stenting in the high-risk patient with severe BA stenosis was adopted realistically. The publication of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke (SAMMPRIS) study demonstrates a higher perioperative stroke rate than medications alone . However, several studies in China show better outcomes of stenting in this condition [7, 8]. Whether the different effects were resulted from different clinical profiles regarding stroke risk and a different response to stenting in Asians depends on further studies . This patient had no perioperative complications as well as no recurrent TIAs or stroke with 6-month follow-up. However, an unexpected hair loss occurred.
Alopecia is a dose-dependent side effect that occurs in radiotherapy . It rarely happens after endovascular angioplasty since its duration is shorter and accumulation of dose of radiation is lower. According to the topography of hair loss patch in this patient, however, which matched the radiation beam, radiation-induced damage rather than an accidental embolization of supply artery branches to the scalp was considered as the major pathogen of alopecia. Nevertheless, it was difficult to exclude other inflammatory or metabolic factors that can result in hair loss. The patient’s comorbid diabetes probably contributed to the focal symptom. Most patients with obesity and type 2 diabetes have insulin resistance, which induces a variety of skin manifestations . The progressive development of insulin resistance induces a cascade of hormonal changes, including an influence on dihydrotestosterone, which is the key androgen that is involved in the pathogenesis of androgenetic alopecia . Meanwhile, in diabetes, inflammatory factors and oxidative stress tangle with many autoimmune and inflammatory skin conditions. The activation as stated above may be an implicit susceptibility of the skin to radiation, while plausible, it remains to have more investigation.
Recovery of provisional alopecia induced by radiation takes several months without additional treatment. As a precaution, it is essential to ensure that the X-ray dose rate is under optimal conditions, which include reduction of the number of fluoroscopic series and frames per series as well as proper filtration material as requested. At the same time, both the rigorous blood glucose administration and the insurance against stress should be included in the perioperative management. Patients should be followed-up if the maximum cumulative absorbed doses to the skin approaching or exceeding 1 Gy with recommendations from International Commission on Radiologic Protection .
Tosti A, Piraccini BM, Alagna G. Temporary hair loss simulating alopecia areata after endovascular surgery of cerebral arteriovenous malformations: a report of 3 cases [J]. Arch Dermatol. 1999;135(12):1555–6.
Wen CS, Lin SM, Chen Y, Chen JC, Wang YH, Tseng SH. Radiation-induced temporary alopecia after embolization of cerebral arteriovenous malformations [J]. Clin Neurol Neurosurg. 2003;105(3):215–7.
Marti N, Lopez V, Pereda C, Martin JM, Montesinos E, Jorda E. Radiation-induced temporary alopecia after embolization of cerebral aneurysms [J]. Dermatol Online J. 2008;14(7):19.
Foroozan M, Bracard S, Schmutz JL. Alopecia after cerebral endovascular procedure [J]. J Eur Acad Dermatol Venereol. 2009;23(5):573–4. https://doi.org/10.1111/j.1468-3083.2008.02957.x.
Vano E, Fernandez JM, Sanchez RM, Martinez D, Ibor LL, Gil A, et al. Patient radiation dose management in the follow-up of potential skin injuries in neuroradiology [J]. AJNR Am J Neuroradiol. 2013;34(2):277–82. https://doi.org/10.3174/ajnr.A3211.
Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial [J]. Lancet. 2014;383(9914):333–41. https://doi.org/10.1016/S0140-6736(13)62038-3.
Jiang WJ, Yu W, Du B, et al. Outcome of patients with >/=70% symptomatic intracranial stenosis after wingspan stenting [J]. Stroke. 2011;42(7):1971–5. https://doi.org/10.1161/STROKEAHA.110.595926.
Yu SC, Leung TW, Lee KT, et al. Angioplasty and stenting of intracranial atherosclerosis with the wingspan system: 1-year clinical and radiological outcome in a single Asian center [J]. J Neurointerv Surg. 2014;6(2):96–102. https://doi.org/10.1136/neurintsurg-2012-010608.
Hussain M, Datta N, Cheng Z, et al. Spanning from the West to East: an updated review on endovascular treatment of intracranial atherosclerotic disease [J]. Aging Dis. 2017;8(2):196–202. https://doi.org/10.14336/AD.2016.0807.
Lawenda BD, Gagne HM, Gierga DP, Niemierko A, Wong WM, Tarbell NJ, et al. Permanent alopecia after cranial irradiation: dose-response relationship [J]. Int J Radiat Oncol Biol Phys. 2004;60(3):879–87. https://doi.org/10.1016/j.ijrobp.2004.04.031.
Gonzalez-Saldivar G, Rodriguez-Gutierrez R, Ocampo-Candiani J, et al. Skin manifestations of insulin resistance: from a biochemical stance to a clinical diagnosis and management [J]. Dermatol Ther (Heidelb). 2017;7(1):37–51. https://doi.org/10.1007/s13555-016-0160-3.
Stefanadi EC, Dimitrakakis G, Antoniou CK, Challoumas D, Punjabi N, Dimitrakaki IA, et al. Metabolic syndrome and the skin: a more than superficial association. Reviewing the association between skin diseases and metabolic syndrome and a clinical decision algorithm for high risk patients [J]. Diabetol Metab Syndr. 2018;10:9. https://doi.org/10.1186/s13098-018-0311-z.
Valentin J. Avoidance of radiation injuries from medical interventional procedures [J]. Ann ICRP. 2000;30(2):7–67. https://doi.org/10.1016/S0146-6453(01)00004-5.
Availability of Data and Materials
The datasets supporting the conclusions of this article are included within the article and its additional files.
Conflict of Interest
All authors declare that they have no competing interests.
Ethics Approval and Consent to Participate
This case report involves a patient. The case report complies with the Helsinki Declaration, and approval was obtained from the ethics committee of PLA Joint Logistics Support Force No.988 Hospital.
Consent for Publication
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor of this journal.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Medicine
About this article
Cite this article
Zhang, P., Fu, W. Reversible Localized Alopecia After Angioplasty of Basilar Artery Stenosis in a Diabetic Patient: a Case Report. SN Compr. Clin. Med. 2, 992–994 (2020). https://doi.org/10.1007/s42399-020-00354-5
- Case report