A large cirsoid aneurysm of the scalp with multiple arterial supply: illustrative case

Soumya Pahari Department of Surgery-Neurosurgical Unit, Shree Birendra Hospital, Kathmandu, Nepal

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Paawan Bahadur Bhandari Department of Surgery-Neurosurgical Unit, Shree Birendra Hospital, Kathmandu, Nepal

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Bibek Bhattarai Department of Neurosurgery, Changhai Hospital, Naval Medical University, Yangpu District, Shanghai, China; and

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Purushottam Baniya Department of Surgery-Neurosurgical Unit, Shree Birendra Hospital, Kathmandu, Nepal

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Stuti Yadav College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal

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Prarthana Subedi College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal

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Sarbind Mandal College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal

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BACKGROUND

Cirsoid aneurysm of the scalp is a rare arteriovenous fistula having a traumatic, congenital, iatrogenic, or idiopathic etiology. Its presentation can range from a small swelling to a large pulsatile mass with tinnitus, headache, and scalp necrosis.

OBSERVATIONS

A 67-year-old female presented with a gradually increasing swelling on her forehead and head since childhood and no history of trauma. Examination revealed 12 × 5 cm tortuous midline swelling. Computed tomography angiography revealed a mass of tortuous vessels in the right frontoparietal region of the scalp with no bony defect or intracranial extension. Contrast-enhanced computed tomography of the head showed no intracranial pathology. The diagnosis of cirsoid aneurysm was made, and surgery was planned.

A bicoronal incision was made. The feeding arteries were dissected and ligated. The nidus was carefully separated, cauterized, and excised in toto. Inadvertently, a buttonhole in the skin was created while dissecting the nidus, which was sutured. The patient developed a small area of scalp necrosis on the 10th postoperative day, which was debrided and sutured. At the 6-month follow-up, no signs of recurrence were present.

LESSONS

A large cirsoid aneurysm of the scalp with multiple arterial supplies can be treated successfully with surgery. Meticulous dissection and hemostasis are warranted to avoid perioperative complications.

ABBREVIATIONS

CECT = contrast-enhanced computed tomography; CTA = computed tomography angiography

BACKGROUND

Cirsoid aneurysm of the scalp is a rare arteriovenous fistula having a traumatic, congenital, iatrogenic, or idiopathic etiology. Its presentation can range from a small swelling to a large pulsatile mass with tinnitus, headache, and scalp necrosis.

OBSERVATIONS

A 67-year-old female presented with a gradually increasing swelling on her forehead and head since childhood and no history of trauma. Examination revealed 12 × 5 cm tortuous midline swelling. Computed tomography angiography revealed a mass of tortuous vessels in the right frontoparietal region of the scalp with no bony defect or intracranial extension. Contrast-enhanced computed tomography of the head showed no intracranial pathology. The diagnosis of cirsoid aneurysm was made, and surgery was planned.

A bicoronal incision was made. The feeding arteries were dissected and ligated. The nidus was carefully separated, cauterized, and excised in toto. Inadvertently, a buttonhole in the skin was created while dissecting the nidus, which was sutured. The patient developed a small area of scalp necrosis on the 10th postoperative day, which was debrided and sutured. At the 6-month follow-up, no signs of recurrence were present.

LESSONS

A large cirsoid aneurysm of the scalp with multiple arterial supplies can be treated successfully with surgery. Meticulous dissection and hemostasis are warranted to avoid perioperative complications.

ABBREVIATIONS

CECT = contrast-enhanced computed tomography; CTA = computed tomography angiography

The cirsoid aneurysm derives its name from the Greek word “to varyx.”1 It is a pathological structure that connects arteries to a vein with variceal dilation of the draining veins. The incidence of cirsoid aneurysms has not been frequently reported, but various case reports and reviews show 200 cases over a duration of 15 years.2 The lesion was first described by Brecht in 18833 and has various etiologies. Their origin can be traumatic, congenital, iatrogenic, or mostly unknown.4 In 90% of the patients, the superficial temporal artery is the main supply of the fistula with one dominant feeding artery in 71% of cases.5 There may also be instances of a dual supply from both the superficial temporal artery and the occipital artery.5,6

Developing initially as a small subcutaneous swelling, they usually progress to a large palpable mass7 with symptoms such as bruits, tinnitus, headache, pain, and scalp necrosis.8 This can cause immense functional, psychological, and social disturbances.9 Angiography is often the investigation of choice.10 Surgery is the predominant treatment, although various endovascular procedures have been described with uncertain benefits.3

We present the case of a large cirsoid aneurysm of the scalp with supplies from multiple feeding arteries. Despite the many cases reported, there are no guidelines on the management, and the treatment depends on the available modalities (endovascular or open surgery) and personal judgment tailored to individual patients. Only a handful of cases with an extensive malformation, a large size, and multiple arterial feeders have been described in the literature. Our case highlights that even in large cirsoid aneurysms, single-stage excision is possible without significant complications and with good cosmetic outcomes in the absence of endovascular modalities and preoperative embolizations in a low-resource setting.

Illustrative Case

History and Examination

A 67-year-old female with no known comorbidities presented to the neurosurgical outpatient department with the complaint of a gradually increasing swelling on her forehead and head since childhood. The swelling started growing rapidly over the past 6 months, and she started experiencing discomfort with occasional headaches, which made her seek medical attention. She did not recall any trauma to the scalp during childhood. Her past medical history and family history were noncontributory.

On examination, there were multiple, tortuous, and irregular swellings in the right frontal, temporal, and parietal regions of the scalp. The largest swelling in the midline was approximately 12 × 5 cm, extending from the glabella to the vertex of the skull (Fig. 1). It was pulsatile and fluctuant on palpation. There were no overlying skin changes such as ulcerations. A bruit was heard during auscultation. The rest of her physical examination, including the thyroid examination, was unremarkable.

FIG. 1
FIG. 1

Anterior (A) and superior (B) views of the scalp and a preoperative image (C) showing multiple, tortuous, and irregular swellings in the scalp, largest in the midline with a size of approximately 12 × 5 cm, extending from the glabella to the vertex of the skull.

Imaging Investigation

A contrast-enhanced computed tomography (CECT) scan of the head was taken, which revealed a dilated, tortuous mass of vessels in the scalp in the frontal and parietal regions with no bony defect, intracranial extension, or identifiable intracranial pathology. A computed tomography angiography (CTA) scan revealed a mass of tortuous vessels in the right frontal and parietal regions (Fig. 2). The nidus was fed by branches of the right superficial temporal, supraorbital, and occipital arteries.

FIG. 2
FIG. 2

A–D: CTA of the external carotid arteries with three-dimensional reconstruction. A mass of tortuous vessels in the right frontal temporal and parietal regions (arrows). The nidus was fed by branches of the branches of right superficial temporal (1), supraorbital (2), and occipital (3) arteries.

Treatment

The diagnosis of cirsoid aneurysm of the scalp was made, and the patient was taken for surgery. A bicoronal incision was made to retract the flap of the scalp. The feeding arteries (right superficial temporal, supraorbital, and occipital arteries) were dissected and ligated with sutures. The nidus was carefully separated from the underlying skin with a scalpel and monopolar and bipolar cautery and was excised in toto. There were also some tiny feeders from the pericranium, which were coagulated. The part of the nidus over the parietal region was densely adherent to the skin and, inadvertently, a 1 × 1 cm buttonhole was created in the skin during dissection which was sutured. The blood loss was approximately 1,000 mL, and the patient did not require blood transfusion.

Postoperative Outcome and Follow-Up

A loose fold of skin over the forehead remained but was free of any pulsations, which was not dealt with because the patient was satisfied with the cosmetic outcome (Fig. 3). The immediate postoperative period was uneventful. CTA done on the second postoperative day showed complete obliteration of the nidus and feeding arteries (Fig. 4). However, the patient developed an area of scalp necrosis of approximately 0.5 × 0.5 cm on the 10th postoperative day, which was debrided and sutured. The patient was discharged on postoperative day 14. At the 6-month follow-up, the patient was doing well with no signs of recurrence.

FIG. 3
FIG. 3

Postoperative status (A). A loose fold of skin over the forehead remained but was free of any pulsation (B).

FIG. 4
FIG. 4

Postoperative CTA on the second postoperative day showed complete obliteration of the nidus and feeding arteries.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

Cirsoid aneurysms of the scalp are rare vascular abnormalities characterized by arteriovenous fistulas.11 They can have various etiologies, including trauma, congenital factors, iatrogenic causes, or idiopathic origins.1,11 In most cases, a single arterial supply, commonly the superficial temporal artery, is involved.5 However, our case highlights the unique instance of a large cirsoid aneurysm with multiple arterial supplies, including the right superficial temporal, supraorbital, and occipital arteries.

The patient in our case was a 67-year-old female who had presented with a gradually increasing swelling on her forehead and head since childhood. The swelling had become more prominent over the past 6 months and was accompanied by discomfort and occasional headaches. Notably, the patient did not recall any history of trauma to the scalp. Upon examination, a large, tortuous, and irregular midline swelling measuring approximately 12 × 5 cm was observed, extending from the glabella to the vertex of the skull. The swelling was pulsatile, fluctuant, and exhibited a bruit on auscultation.

A CECT scan of the head revealed a dilated tortuous mass of vessels in the scalp without any intracranial pathology. Further investigation via CTA provided detailed information about the lesion, highlighting its connection with the branches of the right superficial temporal, supraorbital, and occipital arteries. Importantly, no bony defects or intracranial extension/communication was observed.

Based on the diagnosis of a cirsoid aneurysm of the scalp, surgical intervention was planned. A bicoronal incision was made to expose the scalp. The feeding arteries, including the right superficial temporal, supraorbital, and occipital arteries, were meticulously dissected and ligated using sutures. The nidus, the abnormal vascular network, was then carefully separated from the underlying skin using a scalpel and monopolar and bipolar cautery and was excised completely. In the process of dissection, a buttonhole defect approximately 1 × 1 cm was inadvertently created in the skin. However, it was repaired with sutures without postoperative consequences. The surgical procedure resulted in blood loss of approximately 1 L. After the surgery, a pulsation-free skinfold remained over the forehead. The pericranial feeder vessels were also coagulated, because failure to do so has been shown to increase the risk of recurrence.8

The immediate postoperative period was generally uneventful; however, the patient developed a small area of scalp necrosis measuring approximately 0.5 × 0.5 cm on the 10th postoperative day. The necrotic tissue was debrided, and the wound was sutured. The patient was discharged on postoperative day 14 and followed up at the 6-month mark, showing no signs of recurrence.

Excision is the preferred treatment for cirsoid aneurysms. It offers effective symptom resolution, low complication rates, minimal recurrence, cost-effectiveness, and satisfactory cosmetic outcomes.3,12–15 In our case, excision of the nidus and ligation of the feeding arteries proved to be an effective treatment strategy. Although excision is the mainstay of treatment, various endovascular procedures have been described in the management of cirsoid aneurysms.1

Perioperative hemorrhage and the need for a larger excision of the scalp area that requires reconstructive procedures are the challenges that are faced with excision. This is especially true for large cirsoid aneurysms. This forms the basis for recommending combined endovascular procedures and excision for lesions larger than 4 cm.11 Neoadjuvant endovascular embolization before excision is practiced in large cirsoid aneurysms with multiple feeders to reduce the need for extensive resection and bleeding. However, its complications include pain and residual lesions.16

Wajnberg16 reported four cases of scalp cirsoid aneurysms treated solely by an endovascular modality (direct puncture and injection of cyanoacrylate in one case and transarterial embolization in three cases) with good outcomes. However, all the patients in their series had direct high-flow fistulas without a plexiform component or nidus and were smaller in size compared to our case. Gupta et al.17 described 15 cases treated with an endovascular modality (range of lesion size: 2 × 2 to 6 × 6 cm) without any clinical recurrence. All cases underwent direct puncture and embolization with additional transarterial embolization in a few patients who had a supply from deeper arteries. The complications described were pain and thrombosis at the site of injection, the need for subsequent excision for cosmetic reasons in two cases, and spilling of glue material into the external jugular vein in one patient with a large occipital scalp lesion.17 In a series of six cases by AlFawaz et al.,18 one underwent preoperative intraarterial embolization. However, it did not abolish the pulsation completely and was resected surgically. The technical difficulty in abolishing all the deep feeding vessels completely is one of the major pitfalls of endovascular modalities. Before the advent of endovascular modalities, cirsoid aneurysms were traditionally managed by excision. Torrential intraoperative hemorrhage is a feared complication of the excision of cirsoids.8,19 In the absence of formal guidelines, the treatment strategy is guided by the size and angioarchitecture of the lesion. Based on a review article including 242 cases, Sofela et al.11 proposed a management algorithm in which large lesions (>4 cm) are to be managed with combined excision and endovascular intervention, whereas smaller lesions (<4 cm) are to be managed with endovascular intervention alone, surgery alone, or both depending on the lesion’s angioarchitecture. Of note, the complication rate in patients undergoing endovascular embolization alone was much higher (59.8%) than the rate in those treated with excision only (9.9%). Postoperative pain and the presence of a residual mass were the most frequent complications in the endovascular group. In contrast, scalp necrosis and wound infection were the most frequent complications in the excision group. The neoadjuvant use of endovascular embolization minimizes blood loss and the need for extensive resection, hence the need for extensive reconstructive procedures.3

In low-resource settings like ours (Nepal), the availability and affordability of endovascular intervention is also a major guiding factor for the treatment strategy. Agrawal20 described the case of a large cirsoid (8 × 8 cm) from Nepal, diagnosed via color Doppler of the scalp and treated successfully by excision alone, without angiography facilities and endovascular intervention. Munakomi et al.19 described another case from Nepal, sized 12 × 4 cm with extensive collaterals in which multiple attempts at excision failed because of excessive hemorrhage and was treated with preoperative embolization followed by excision and reconstruction. Endovascular surgery was not considered in our case because it is unavailable at our center and the patient’s constrained financial condition for referral to other centers.

Although the surgical procedure resulted in a significant blood loss of approximately 1 L, appropriate management and close monitoring ensured a successful outcome. The key to excision alone in the illustrated case with extensive malformation was meticulous dissection and hemostasis. We emphasize that taking control of the pericranial feeders is crucial, because it is a source of bleeding and recurrence and is often not visualized on imaging. The development of a small area of scalp necrosis, likely from a compromised blood supply due to ligation of scalp vessels, highlights the importance of postoperative care and prompt management of complications. The debridement and suturing of the necrotic area facilitated proper wound healing and prevented further complications.

Thorough preoperative planning is crucial to effectively manage potential contingencies encountered during surgical procedures.6 Fortunately, a noteworthy observation in a significant subset of patients with these intricate lesions is the presence of an augmented scalp thickness, thereby facilitating the dissection process. However, it is imperative to use bipolar diathermy at the minimal operative power setting and exercise meticulous sharp dissection techniques to ensure successful excision of the lesion. During the dissection phase, utmost care should be taken to maintain an appropriate distance from the skin surface to avoid the inadvertent creation of buttonholes. Furthermore, meticulous attention must be paid to prevent inadvertent penetration into the lesion itself, as such occurrences can result in profuse hemorrhage that may be life-threatening and necessitate prompt management.6

Long-term follow-up is essential in cases of cirsoid aneurysms of the scalp to monitor for any signs of recurrence or complications. In our case, the patient remained asymptomatic without any evidence of recurrence at the 6-month follow-up, indicating a successful surgical outcome.

Lessons

Cirsoid aneurysms of the scalp are rare vascular abnormalities that present unique diagnostic and therapeutic challenges. Our case highlights the successful surgical management of a large cirsoid aneurysm with multiple arterial supplies. Meticulous excision of the nidus, along with ligation of the feeding arteries, resulted in the resolution of symptoms and a favorable outcome. Accidentally, a buttonhole was created during excision, which is a limitation of our study. This emphasizes the need for meticulous surgery.

Although neoadjuvant endovascular approaches have been described for larger lesions, their benefits and long-term efficacy remain uncertain and are not available in low-resource settings like ours. Further studies and larger case series are warranted to evaluate the optimal management strategies and long-term outcomes of cirsoid aneurysms of the scalp.

Author Contributions

Conception and design: Pahari, Bhandari, Baniya, Subedi. Acquisition of data: Pahari, Bhandari, Bhattarai, Subedi, Mandal. Analysis and interpretation of data: Pahari, Bhandari, Bhattarai, Yadav, Mandal. Drafting the article: Pahari, Bhandari, Yadav, Subedi. Critically revising the article: all authors. Reviewed submitted version of manuscript: Pahari, Bhandari, Bhattarai, Mandal. Approved the final version of the manuscript on behalf of all authors: Pahari. Administrative/technical/material support: Bhandari, Baniya. Study supervision: Pahari, Bhandari, Baniya.

Supplemental Information

Previous Presentations

 Abstract presented at the Congress of Neurological Surgeons 2023 Annual Meeting, Washington, DC, September 9–13, 2023, as a “digital only” poster.

References

  • 1

    Albuquerque Sousa LH, Maranha Gatto LA, Demartini Junior Z, Koppe GL Scalp cirsoid aneurysm: an updated systematic literature review and an illustrative case report. World Neurosurg. 2018;119:416427.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Karsy M, Raheja A, Guan J, Osborn AG, Couldwell WT Scalp arteriovenous malformation with concomitant, flow-dependent malformation and aneurysm. World Neurosurg. 2016;90:708.e5708.e9.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Furtado SV, Srinivasa R, Vala K, Mohan D Contemporary management of scalp cirsoid aneurysm: a dual-trained neurosurgeon’s perspective. Clin Neurol Neurosurg. 2021;201:106437.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Gangadharaswamy SB, Maulyavantham Nagaraj N, Pai BS Surgical management of scalp arteriovenous malformations using a novel surgical technique-Case series. Int J Surg Case Rep. 2017;37:250253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Gurkanlar D, Gonul M, Solmaz I, Gonul E Cirsoid aneurysms of the scalp. Neurosurg Rev. 2006;29(3):208212.

  • 6

    Muthukumar N, Rajagopal V, Manoharan AV, Durairaj N Surgical management of cirsoid aneurysms. Acta Neurochir (Wien). 2002;144(4):349356.

  • 7

    Ni W, Tian Y, Gu Y, Mao Y Transvenous endovascular treatment for scalp arteriovenous fistulas: results with combined use of onyx and coils. World Neurosurg. 2017;107:692697.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Fisher-Jeffes ND, Domingo Z, Madden M, de Villiers JC Arteriovenous malformations of the scalp. Neurosurgery. 1995;36(4):656660, discussion 660.

  • 9

    Shenoy SN, Raja A Scalp arteriovenous malformations. Neurol India. 2004;52(4):478481.

  • 10

    Tauro LF, Suhith G, Shetty P, Rao D Cirsoid aneurysm of scalp. J Neurosci Rural Pract. 2012;3(1):9596.

  • 11

    Sofela A, Osunronbi T, Hettige S Scalp cirsoid aneurysms: case illustration and systematic review of literature. Neurosurgery. 2020;86(2):E98E107.

  • 12

    Karki M, Roka YB surgical excision of cirsoid aneurysm of the scalp: case series and review of the literature. World Neurosurg. 2021;155:e600e604.

  • 13

    ElKiran YM, Abdelgawwad MS, Abdelmaksoud MA, Elwakeel HA, Elshafei AM Surgical management of cirsoid aneurysms of the scalp: ten years’ experience. World Neurosurg. 2021;150:e756e764.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kumar R, Sharma G, Sharma BS Management of scalp arterio-venous malformation: case series and review of literature. Br J Neurosurg. 2012;26(3):371377.

  • 15

    El Shazly AA, Saoud KMF Results of surgical excision of cirsoid aneurysm of the scalp without preoperative interventions. Asian J Neurosurg. 2012;7(4):191196.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Wajnberg E Endovascular treatment of scalp cirsoid aneurysms. Radiol Bras. 2010;43:224228.

  • 17

    Gupta AK, Purkayastha S, Bodhey NK, et al. Endovascular treatment of scalp cirsoid aneurysms. Neurol India. 2008;56(2):167172.

  • 18

    AlFawaz AA, AlShatti HJ, Safar AH Surgical management of scalp cirsoid aneurysms: Kuwait experience. (case series). Ann Med Surg (Lond). 2022;76:103479.

  • 19

    Munakomi S, Bhattarai B, Cherian I Conquering the odds: cirsoid aneurysm with holocranial feeders-staged embolization, excision and grafting. Asian J Neurosurg. 2015;10(3):259261.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Agrawal A Cirsoid aneurysm with impending rupture. Pakistan Journal of Neurological Sciences. 2009;4(2):7476.

  • Collapse
  • Expand
  • FIG. 1

    Anterior (A) and superior (B) views of the scalp and a preoperative image (C) showing multiple, tortuous, and irregular swellings in the scalp, largest in the midline with a size of approximately 12 × 5 cm, extending from the glabella to the vertex of the skull.

  • FIG. 2

    A–D: CTA of the external carotid arteries with three-dimensional reconstruction. A mass of tortuous vessels in the right frontal temporal and parietal regions (arrows). The nidus was fed by branches of the branches of right superficial temporal (1), supraorbital (2), and occipital (3) arteries.

  • FIG. 3

    Postoperative status (A). A loose fold of skin over the forehead remained but was free of any pulsation (B).

  • FIG. 4

    Postoperative CTA on the second postoperative day showed complete obliteration of the nidus and feeding arteries.

  • 1

    Albuquerque Sousa LH, Maranha Gatto LA, Demartini Junior Z, Koppe GL Scalp cirsoid aneurysm: an updated systematic literature review and an illustrative case report. World Neurosurg. 2018;119:416427.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Karsy M, Raheja A, Guan J, Osborn AG, Couldwell WT Scalp arteriovenous malformation with concomitant, flow-dependent malformation and aneurysm. World Neurosurg. 2016;90:708.e5708.e9.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Furtado SV, Srinivasa R, Vala K, Mohan D Contemporary management of scalp cirsoid aneurysm: a dual-trained neurosurgeon’s perspective. Clin Neurol Neurosurg. 2021;201:106437.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Gangadharaswamy SB, Maulyavantham Nagaraj N, Pai BS Surgical management of scalp arteriovenous malformations using a novel surgical technique-Case series. Int J Surg Case Rep. 2017;37:250253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Gurkanlar D, Gonul M, Solmaz I, Gonul E Cirsoid aneurysms of the scalp. Neurosurg Rev. 2006;29(3):208212.

  • 6

    Muthukumar N, Rajagopal V, Manoharan AV, Durairaj N Surgical management of cirsoid aneurysms. Acta Neurochir (Wien). 2002;144(4):349356.

  • 7

    Ni W, Tian Y, Gu Y, Mao Y Transvenous endovascular treatment for scalp arteriovenous fistulas: results with combined use of onyx and coils. World Neurosurg. 2017;107:692697.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Fisher-Jeffes ND, Domingo Z, Madden M, de Villiers JC Arteriovenous malformations of the scalp. Neurosurgery. 1995;36(4):656660, discussion 660.

  • 9

    Shenoy SN, Raja A Scalp arteriovenous malformations. Neurol India. 2004;52(4):478481.

  • 10

    Tauro LF, Suhith G, Shetty P, Rao D Cirsoid aneurysm of scalp. J Neurosci Rural Pract. 2012;3(1):9596.

  • 11

    Sofela A, Osunronbi T, Hettige S Scalp cirsoid aneurysms: case illustration and systematic review of literature. Neurosurgery. 2020;86(2):E98E107.

  • 12

    Karki M, Roka YB surgical excision of cirsoid aneurysm of the scalp: case series and review of the literature. World Neurosurg. 2021;155:e600e604.

  • 13

    ElKiran YM, Abdelgawwad MS, Abdelmaksoud MA, Elwakeel HA, Elshafei AM Surgical management of cirsoid aneurysms of the scalp: ten years’ experience. World Neurosurg. 2021;150:e756e764.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kumar R, Sharma G, Sharma BS Management of scalp arterio-venous malformation: case series and review of literature. Br J Neurosurg. 2012;26(3):371377.

  • 15

    El Shazly AA, Saoud KMF Results of surgical excision of cirsoid aneurysm of the scalp without preoperative interventions. Asian J Neurosurg. 2012;7(4):191196.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Wajnberg E Endovascular treatment of scalp cirsoid aneurysms. Radiol Bras. 2010;43:224228.

  • 17

    Gupta AK, Purkayastha S, Bodhey NK, et al. Endovascular treatment of scalp cirsoid aneurysms. Neurol India. 2008;56(2):167172.

  • 18

    AlFawaz AA, AlShatti HJ, Safar AH Surgical management of scalp cirsoid aneurysms: Kuwait experience. (case series). Ann Med Surg (Lond). 2022;76:103479.

  • 19

    Munakomi S, Bhattarai B, Cherian I Conquering the odds: cirsoid aneurysm with holocranial feeders-staged embolization, excision and grafting. Asian J Neurosurg. 2015;10(3):259261.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Agrawal A Cirsoid aneurysm with impending rupture. Pakistan Journal of Neurological Sciences. 2009;4(2):7476.

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