Endovascular treatment of cirsoid aneurysms: A stepwise approach to successful embolization

Abstract

Cirsoid aneurysms, a subtype of arteriovenous fistulas (AVF), of the scalp are rare pathological lesions characterized by abnormal fistulous connections between superficial arteries and draining veins without intervening capillary beds. We present a case report of a cirsoid aneurysm located on the scalp, treated at our tertiary care center using percutaneous endovascular intervention with injection embolics. This report highlights the challenges posed by complex vascular anatomy and high shunt flow in the treatment of such lesions involving the head and neck. We discuss the rationale for selecting the treatment approach, emphasizing the importance of a patient-specific strategy to achieve successful obliteration of the abnormal vascular connections. Our experience underscores the efficacy of transarterial and/or transvenous embolization using appropriate embolic materials in the management of cirsoid aneurysms. This case report contributes to the existing literature on treatment options for scalp AVFs, providing insights into optimizing outcomes in these rare but clinically significant lesions.

Keywords: Arteriovenous fistula; Cirsoid aneurysm; Endovascular embolization.

Fig. 1

Contrast-enhanced CT of the head at the level of the orbits demonstrates a large, avidly enhancing vascular malformation along the right temporal scalp, with a nidus in the right supraorbital region.

Fig. 2

Subselective lateral angiogram of the internal maxillary artery shows vascular supply to the right supraorbital cirsoid malformation, draining into multiple venous territories.

Fig. 3

3D rotational angiogram demonstrates right periorbital arteriovenous fistula (A). Lateral projection right external carotid artery angiogram demonstrates multiple feeders to the fistula pouch from the right superficial temporal artery (B).

Fig. 4

Lateral projection angiogram through the Scepter XC balloon catheter demonstrates supply to the fistula from the right superficial temporal artery branch that is catheterized (A). Lateral projection right superficial temporal artery angiogram through a distal access catheter demonstrates supply to the fistula from the superficial temporal artery frontal branches (B). Lateral projection right superficial temporal artery angiogram through a DAC catheter demonstrates occlusion of supply to the fistula from the superficial temporal artery frontal branches with onyx cast (C).

Fig. 5

Lateral angiogram of the internal maxillary artery postembolization demonstrates nonvisualization of the cirsoid malformation, consistent with complete embolization.

Fig. 6

Intraoperative image following embolization shows a large bulbar mass that was completely excised with minimal bleeding.