A giant challenge: Hybrid management of a scalp and neck cirsoid aneurysm

Cirsoid aneurysms are rare, high-flow arteriovenous malformations (AVMs) of the scalp and neck, formed by direct arteriovenous shunts without an intervening capillary bed. They may present with pulsatile swelling, bruit, cosmetic disfigurement, pain, or hemorrhage. Giant, diffuse lesions with feeders from multiple vascular territories are uncommon and pose significant therapeutic challenges.

A 24-year-old male presented with a 10-12-year history of an enlarging occipital mass, which had rapidly increased in size over the preceding 2-3 years. Examination revealed a pulsatile, warm lesion extending anteriorly to the neck (right > left) with overlying skin thinning and discoloration; a loud bruit was audible. Computed tomography angiography demonstrated a 24 × 22 cm high-flow AVM supplied by multiple feeders from the external carotid and vertebral arteries, with venous drainage into the right internal jugular vein. Preoperative super-selective embolization was performed to reduce vascularity, followed by en bloc surgical resection along the pericranial plane with ligation of all feeders. Reconstruction was achieved using a split-thickness skin graft harvested from the thigh. The initial recovery was uneventful, with complete graft uptake. At 3 months, recurrence secondary to neoangiogenesis was treated with repeat embolization and adjuvant external beam radiotherapy. At the latest follow-up, the graft remained healthy, with no further bleeding or lesion progression.

Giant scalp and neck cirsoid aneurysms require meticulous preoperative imaging, staged endovascular flow reduction, complete surgical excision, and coordinated multidisciplinary management. Recurrence from collateral vessel formation may occur despite optimal therapy, underscoring the importance of long-term clinical and radiological surveillance.