Management of Large Cirsoid Aneurysms of the Scalp Using Tissue Expanders, Intravascular Occlusion, and En Bloc Excision

Background: Arteriovenous malformations of the scalpconsist of abnormally connecting arterial feeding vessels anddraining veins that are devoid of a normal capillary bed withinthe subcutaneous fatty layer of the scalp. The name "cirsoid"in cirsoid aneurysm is derived from the Greek word kirsosmeaning varix or varicose vein. The en bloc excision of scalptissues affected by aneurysm is preferable to selective ligationof the feeding and draining vessels. Because the managementof cirsoid aneurysm is an elective procedure, it is best to usetissue expanders to create sufficient scalp flaps to reconstructthe site of the excised lesion in the first stage. Preoperativeembolization greatly reduces blood loss during resection.Aim of the Work: To present the successful managementof cirsoid aneurysms of the scalp using tissue expanders,endovascular occlusion, and en bloc excision.Material and Methods: Five patients who had presentedcirsoid aneurysms of the scalp (two temporoparietal, twofrontal, and one occipital) were managed successfully usingthree stages of intervention. The first stage was the applicationof one or two tissue expanders, in which expanders wereapplied under the normal (non-affected) scalp in the subgalealplane; expansion was then performed weekly for 3-4 months.The second stage involved endovascular occlusion throughendovascular neuroradiology. The third stage was performedthe day after occlusion and included en bloc excision, thedelivery of tissue expanders, and reconstruction of the site ofexcision using scalp flaps. The postoperative period wasuneventful. Six months to three years of following-up showedno recurrence.Conclusion:We conclude that the three-stage managementof large cirsoid aneurysms of the scalp (application of tissueexpanders, endovascular occlusion, then en bloc excision andreconstruction) provides excellent results.