Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 8  |  Issue : 6  |  Page : 804-806  

Cirsoid aneurysm of scalp: Value of multidetector CT scan in pre-operative evaluation


1 Department of Radiology, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
2 Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication19-Nov-2015

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.169940

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  Abstract 

Cirsoid aneurysm of scalp is a rare arteriovenous malformation (AVM) of external carotid branches and scalp veins. This malformation of scalp is also synonymously called as plexiform angioma, aneurysma racesomsum, and aneurysm cirsoide, aneurysma serpentinum. This AVM can be congenital or acquired; a congenital form will be present at birth, however, becomes overt only after puberty. Superficial temporal artery is the feeder in approximately 70-80% of the cases, followed by occipital and supraorbital artery. Multidetector computed tomography angiography reconstructed images can provide excellent detail of the feeders, draining veins and their soft tissue relations. Volume rendering data sets in computer workstations we can actually perform virtual dissection layers of the lesion for operative planning. Well planned surgical excision can have least surgical recurrence rates and complications.

Keywords: Arteriovenous malformation of scalp, cirsoid aneurysm, external carotid supply, occipital artery, temporal artery


How to cite this article:
Reddy V U, Harisha P N, Hegde KV, Agrawal A, Kandukuri K. Cirsoid aneurysm of scalp: Value of multidetector CT scan in pre-operative evaluation. Med J DY Patil Univ 2015;8:804-6

How to cite this URL:
Reddy V U, Harisha P N, Hegde KV, Agrawal A, Kandukuri K. Cirsoid aneurysm of scalp: Value of multidetector CT scan in pre-operative evaluation. Med J DY Patil Univ [serial online] 2015 [cited 2019 Sep 19];8:804-6. Available from: http://www.mjdrdypu.org/text.asp?2015/8/6/804/169940


  Introduction Top


Cirsoid aneurysm of scalp is a rare arteriovenous malformation (AVM) of external carotid branches and scalp veins. [1],[2] This AVM can be congenital or acquired; a congenital form will be present at birth, however, becomes overt only after puberty. [1],[2],[3],[4],[5],[6] Acquired malformation is the result of previous trauma, which is often trivial, taking months to years for development of malformation after the traumatic episode. [1] This malformation of scalp is also synonymously called as plexiform angioma, aneurysma racesomsum, and aneurysm cirsoide, aneurysma serpentinum. These abnormal vessel tangles in the scalp are located in the subcutaneous plane and capillary bed, or nidus is absent normally. Arterial feeders for these lesions are mostly from superficial temporal or occipital arteries. [1],[5],[6] Patients present with abnormal pulsatile, cosmetically disfiguring scalp swelling and occasionally with headache and tinnitus. [1],[4],[6],[7] We present a case of cirsoid aneurysm, which was initially mismanaged elsewhere due to lack of appropriate imaging in rural set up. Computed tomography (CT) angiography in our case was imperative in providing the details of the lesion and was very effective for management.


  Case Report Top


A 40-year-old female presented with a slow growing scalp swelling in left occipital region since 5 years. She could not recollect any significant traumatic event in the past. Swelling was compressible and pulsatile, patient had on and off headaches. A local doctor attempted to excise the swelling without proper imaging (anatomy of arterial feeders) which resulted in torrential bleed during surgery, and he discontinued the procedure, after attaining local hemostasis. Patient was referred to our hospital. On examination, swelling showed altered skin color as a result of recent surgery and on palpation there was exquisite thrill from the swelling. After the diagnosis of AVM was made, CT angiography was advised for knowing the dynamics of the aneurysm. Imaging revealed numerous serpinginous vessels from occipital and temporal arteries [Figure 1] and [Figure 2] forming the swelling and were drained into retromandibular veins and then into internal jugular veins. Nonenhancing thrombosed vessels which were the result of previous surgery were also seen. Surgery was planned, and all the feeders were ligated and abnormal vessels were excised with minimal blood loss. Histopathological examination confirmed AVM. Following surgery there was complete resolution in the size of the swelling [Figure 3].
Figure 1: Multidetector computed tomography volume rendered images (a-c) showing arteriovenous malformation of scalp receiving numerous arterial feeders from bilateral superfi cial temporal and posterior occipital arteries, a tiny feeding artery arising from supra orbital artery was also seen

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Figure 2: Axial contrast computed tomography (a), axial and sagittal maximum intensity projection images (b-d) showing entangled serpingnous vessels in the left occipital region with prominent tortuous feeders

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Figure 3: Images (a) showing the presurgical marking of the flap to be resected and excision of the vascular malformation (b and c)

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  Discussion Top


Cirsoid aneurysms were initially called as racemose aneurysm by Virchow, Dupuytren called them as arterial varices. Present term cirsoid aneurysm was coined by Brecht in 1833. [8] Cirsoid aneurysms can have single feeder artery or multiple feeders. Superficial temporal artery is feeder in approximately 70-80% of the cases, followed by occipital and supraorbital artery. [1],[5],[7],[9] In our case, AVM was receiving blood supply from multiple feeding arteries from ipsilateral superficial temporal, occipital, supraorbital arteries and contralateral occipital arteries. [1],[5],[7],[9] Demonstrating angioarchitexture is pivotal in managing these malformations. Conventional angiography is a gold standard in diagnosing these lesions, however recently it has been largely replaced by CT/magnetic resonance angiography because of their noninvasiveness. [3],[5] Multidetector CT angiography reconstructed images can provide excellent detail of the feeders, draining veins and their soft tissue relations. [5] With recent volume rendering data sets in computer workstations, we can actually perform virtual dissection layers of the lesion for operative planning. [5] Multiple treatment options are available for treating this malformation like local sclerosant injection, endovascular treatment, and surgical ligation of arterial feeders following by excision. [1],[6],[7] Endovascular treatment is proven efficient method of dealing with cirsoid aneurysms, recurrence can occur following the endovascular treatment as there may be a recruitment of the arterial feeders from other branches of the external carotid arteries. [1],[6],[7] Surgery should be the procedure of choice whenever imaging demonstrates more complex angioarchitexture. [1] Well planned surgical excision can have least surgical recurrence rates and complications. [1]


  Conclusion Top


Cirsoid aneurysm of scalp is clinically simple diagnosis when thrill in the swelling is obvious, differential diagnosis for these lesions include temporal artery pseudo aneurysm and follicular carcinoma metastases. Role of imaging is to narrow the differential diagnosis and to provide details about anatomy and physiology of the lesions helpful for surgery. Catheter angiography is a gold standard in diagnosing these malformations. CT angiography gives detail about the arterial feeders and draining vessels on par with conventional angiography. Volume rendered images and maximum intensity projection images on multidetector CT give excellent detail about the blood supply helping the surgeon for preoperative planning to achieve minimal blood loss during surgery.

 
  References Top

1.
Shenoy SN, Raja A. Scalp arteriovenous malformations. Neurol India 2004;52:478-81.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Weinzweig N, Chin G, Polley J, Charbel F, Shownkeen H, Debrun G. Arteriovenous malformation of the forehead, anterior scalp, and nasal dorsum. Plast Reconstr Surg 2000;105: 2433-9.  Back to cited text no. 2
    
3.
Chakraborti K, Mar SK, Tripathi R, Mehta N. Conventional and magnetic resonance angiographic evaluation of cirsoid aneurysm. Neurol India 1998;46:44.  Back to cited text no. 3
    
4.
El Shazly AA, Saoud KM. Results of surgical excision of cirsoid aneurysm of the scalp without preoperative interventions. Asian J Neurosurg 2012;7:191-6.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Goel V, Verma AK, Singh S, Puri SK. Cirsoid aneurysm of scalp: Demonstration on CT angiography (CTA). BMJ Case Rep 2013;2013:bcr2013202459.  Back to cited text no. 5
    
6.
Gupta AK, Purkayastha S, Bodhey NK, Kapilamoorthy TR, Krishnamoorthy T, Kesavadas C, et al. Endovascular treatment of scalp cirsoid aneurysms. Neurol India 2008;56:167-72.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Tauro LF, Suhith G, Shetty P, Rao D. Cirsoid aneurysm of scalp. J Neurosci Rural Pract 2012;3:95-6.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Grimes OF, Freeman NE. Cirsoid aneurysm of the scalp: Report of a case. Ann Surg 1949;129:123-30.  Back to cited text no. 8
    
9.
Corr PD. Cirsoid aneurysm of the scalp. Singapore Med J 2007;48:e268-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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