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Background Cirsoid aneurysms, also known as arteriovenous malformations (AVMs), of the scalp are relatively rare lesions. They may be found incidentally or with symptoms such as an enlarging pulsatile mass, headache, or bleeding. Methods This retrospective case series comprised 10 cases of scalp AVMs that were treated with surgical excision from January 2010 to January 2020. Diagnosis was made with simple palpation and computed tomography angiography. Scalp AVMs were categorized according to the Schobinger classification. Results There were 10 patients, 8 males and 2 females, with a mean age of 22.6 years (range, 10–40 years). All patients underwent ligation of the feeding artery with total excision of the AVM. There were no postoperative complications or recurrences during a mean follow-up of 21.6 months. Conclusions Preoperative embolization reduces vascularity and helps in easy identification as well as complete excision of cirsoid aneurysms during surgery. However, surgical excision alone of cirsoid aneurysms also results in excellent outcomes.

An arteriovenous malformation is a rare vascular anomaly composed of a complex network of interconnected arteries and veins of the scalp. It is usually congenital, but infrequently occurs after trauma. Over the years, several terms have been used to describe these lesions, such as cirsoid/rasemose/arteriovenous aneurysm, plexiform angioma and aneurysma serpentinum, or arteriovenous fistula when a single connection exists. Head and neck malformations occur in 0.1% of the population. Involvement of the superficial temporal artery is rare, occurring in about 0.5% to 2.0% of cases. They are diagnosed by angiography and can be managed by endovascular or open resection. The case of a 23-year-old man who presented with a pulsatile head mass after blunt trauma 5 years prior is presented. This entity was diagnosed as an arteriovenous malformation supplied by the superficial temporal arteries. He subsequently underwent successful open exploration and resection. The information is presented with the patient's consent. Keywords: Trauma, Arteriovenous fistula, Superficial temporal artery, Vascular abnormalities, Cirsoid aneurysm

Scalp cirsoid aneurysm, also known as arteriovenous fistula, is a rare condition that commonly presents with a pulsatile cutaneous mass. Angiography is the gold standard for diagnosing this rare lesion. Here, we report the case of a 21-year-old woman who presented with a 7-year subcutaneous pulsatile mass over the suboccipital region. Computed tomographic angiography and conventional angiography confirmed the diagnosis of scalp cirsoid aneurysm. No residual or recurrent fistulas were observed after treatment with only endovascular embolization.

Objective Cirsoid aneurysms are rare arteriovenous malformations of the scalp that present with disfigured pulsatile masses and may be associated with headache, bleeding, or tinnitus. These lesions are difficult to manage because of their complex vascular anatomy, high shunt flow, and cosmetic disfigurement; many options have been described to treat such lesions. We evaluate 10 years’ experience in the surgical management of cirsoid aneurysms of the scalp. Methods This study included 15 patients with cirsoid aneurysm of the scalp, all of whom were treated with surgical excision only over 10 years. They were 8 females and 7 males, with a median age of 23 years. History of trauma was present in 5 patients. Frontal and parietal regions were the commonly affected sites. Superficial temporal, supraorbital, and occipital arteries were the most frequent feeding arteries. Results Excision of the lesion was performed in all patients using our modified surgical technique. All patients had good cosmetic results and there were no recurrences during an average follow-up of 25 months. Conclusions Despite great progress in endovascular therapy, surgical excision of cirsoid aneurysms of the scalp seems to be the most effective treatment, with good results and patient satisfaction.

Cirsoid aneurysms are rare arteriovenous malformations without any capillaries interposed and almost always observed in the scalp region. These types of aneurysms are so-called “cirsoid” because of their serpiginous appearance. In this report, the authors present the first case of a lethal spontaneous rupture of a cirsoid aneurysm of the splenic artery, which could be diagnosed only by post-mortem histologic examination. The victim was a 70-year-old man who was suddenly found dead in bed while he was hospitalized and waiting for a scheduled cardiac surgery. A forensic autopsy was ordered due to the suspicion that the man's death could have been related to medical malpractice. An accurate autopsy and a complete forensic histologic examination could clarify the cause of death, which was identified in the spontaneous rupture of a cirsoid aneurysm of the splenic artery. The case is intended to be used as source data for similar forensic cases, where the cause of a massive hemoperitoneum is difficult to be identified.

Background Arteriovenous malformation of the scalp (sAVM) is a rare pathology that accounts for 8% of all cranial arteriovenous malformations. It is believed to be congenital; however, few reported were secondary to trauma. They are managed either via surgical resection, endovascular embolization, or combined approach. Cases with bilateral dual extracranial feeders are yet significantly scarce incidents among this rare pathology. We report a case of sAVM with dual bilateral feeders and review the literature. Case presentation We report a case of a 24-year-old male who presented with a spontaneous para-midline enlarging mass over five years associated with headache. Imaging, including angiography, showed a subcutaneous vascular lesion measuring 2.4x4.2 cm supplied by bilateral superficial temporal arteries and occipital arteries. The patient underwent endovascular subtotal embolization with subsequent surgical excision with excellent recovery. Conclusion The rare occurrence of sAVMs requires a high index of suspicion and angiographic images to assess blood supply for preoperative embolization. A combined management approach is associated with good outcome and decrease the risk of recurrence.

Background Scalp arteriovenous fistula (SAVF) is relatively rare; due to its rarity, there is currently no established consensus on the treatment strategies of SAVF. Case description A 30-year-old male presented with a pulsating mass on his right forehead. He underwent left selective amygdalohippocampectomy for left temporal lobe epilepsy 18 years prior. Cerebral angiography showed three fistula points that were fed by the bilateral superficial temporal arteries (STA) and an expanding drainage vein. We diagnosed the patient with SAVF. Because the fistula gathered in the midline of the forehead, we planned the treatment with surgical treatment alone. First, the proximal side of the right STA, the main feeder to the fistula, was released and clamped. The fistulas made up of the three shunt points of the STAs on both sides were then detected under a microscope. Then, each of the three feeders from the STAs on both sides was clamped. Three feeding arteries and drainage veins were coagulated, and the fistula was removed. Finally, the patient was discharged without complications, including scalp necrosis, infection, and recurrence of the pulsating mass. Conclusions In our case, SAVF may have occurred after craniotomy or frequent minor head trauma. In direct surgery of SAVF, reliable identification and exposure of the feeder and fistula under a microscope without bleeding are the key. Direct surgery with a small skin incision is possible to cure SAVF completely, especially in cases where a fistula is present.

Objective Scalp cirsoid aneurysms are subcutaneous arteriovenous fistulae fed by branches of the external carotid artery. They present with progressive scalp swelling and cosmetic deformities in addition to neuro-vascular symptoms. We evaluate the treatment and outcome of this rare vascular lesion with surgery and adjunctive endovascular embolisation performed by a dual-trained neurosurgeon. Methods A retrospective analysis of 6 cases operated over a 16 year-period was performed which comprised of clinical data, radiology including angiography and pre-operative embolisation, surgical approaches, outcomes and complications. Results 6 patients with ages ranging between 26 and 51 years were operated in the study period. All the patients underwent surgical excision of the lesion, of which 2 had undergone pre-operative embolisation of the feeders. There was no recurrence in the follow-up period (Mean 4.7 years) following total excision of the lesions. One patient had post-operative wound dehiscence and another had migration of embolic material to lungs. Conclusion Surgery is the predominant treatment method for scalp cirsoid aneurysms. Various adjunctive endovascular procedures can be performed pre-operatively to minimise operative blood loss.Though lower recurrence is seen with surgery for the scalp AV fistula, embolisation performed in select cases can achieve curative results with appropriate techniques.

Scalp cirsoid aneurysm is an arteriovenous fistula of the scalp that is unconnected by intracranial or cerebral vessels. Variceal dilatation of draining veins can produce cosmetic concerns, masses, local pain, palpable thrills, and audible bruits, headache, tinnitus, and hemorrhage. Its etiopathogenesis is not well understood. Treatment includes surgery (fistula repair by simple surgical ligation until gross total resection), embolization (whether percutaneous or endovascular), or a combination of the two. An updated systematic review of the last 10 years publications was performed. Also, we report an illustrative case of a young boy with posttraumatic cirsoid aneurysm and good documentation on head vascular examinations, treated by multiple routes (percutaneous embolization with coils and endovascular embolization with cyanoacrylate) with a decrease of the pulsatile mass. A plastic surgery team performed gross total resection, and the final esthetic result was extremely satisfactory.

Background Scalp arteriovenous malformations, also known as cirsoid aneurysms, are rare lesions that are congenital, traumatic, or postinfectious in nature. These lesions may be found incidentally or owing to signs and symptoms that they produce, such as an enlarging pulsatile mass, headache, tinnitus, or bleeding. These lesions often constitute high-flow arterial blood from the superficial temporal or occipital arteries with venous outflow into extracranial venous structures. Methods We describe diagnosis and management of 2 cases of congenital scalp arteriovenous malformations in adolescent patients. One case had more typical vascular supply and outflow, whereas the other case demonstrated more uncommon arterial blood supply from extracranial ophthalmic arteries as well as a component of transosseous venous drainage into the intracranial superior sagittal sinus via emissary veins. Results Treatment of these lesions usually consists of endovascular embolization followed by surgical resection. Conclusions Both scalp AVMs described were successfully excised after transvenous embolization. Consideration of risks of intracranial venous drainage must be taken into account when evaluating AVM anatomy.

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.

Scalp arteriovenous malformations (AVMs) are rare entities that may present as large, tortuous vascular lesions with resultant craniofacial deformity. Radiologic findings include feeding arteries and veins associated with dilated tortuous vessels. Intracranial extension is rare. A 5-year-old African American male presented with an occipital mass presumed to be a dermoid cyst on referral. Further workup revealed the presence of a scalp AVM that demonstrated extension into the left sigmoid sinus. Radiologic and intraoperative images are presented. Literature search revealed only 4 patients with scalp AVM extending intracranially into the sagittal sinus, 2 of which were managed with coagulation and division of the feeding vessels and the other 2 underwent preoperative embolization. Our patient is the 1st to be reported to have sigmoid sinus extension. Scalp AVMs with intracranial extension are rare, and require further preoperative workup. Following ultrasound evaluation, computed tomography angiography, magnetic resonance angiography, magnetic resonance imaging, or cerebral angiography can be considered. Treatment entails resection, but preoperative embolization is increasingly used, mirroring patients without intracranial extension. Further studies are needed to evaluate the efficacy and risk profile of these treatments.

Highlights • Total surgical excision is the only modality which guarantees a cure. • Surgical excision is challenging due to troublesome intraoperative bleeding. • Novel technique of temporary proximal feeding artery control and clipping prior to nidus excision. • Results in decreased intra operative blood loss and operative time. • Good outcome., Introduction Scalp AVM (SAVM) is a rare condition. Although surgical excision is considered as definitive treatment for these lesions, troublesome intraoperative bleeding may pose a challenge. Embolization as an alternative modality is gaining popularity. Proximal feeding artery temporary clipping has been utilized by the authors in this series to address troublesome intraoperative bleeding. Presentation of cases The authors present their experience in the surgical management of 3 cases with SAVMs using proximal feeding artery temporary occlusion followed by total surgical excision. The clinical presentations and radiological features of these cases are discussed in the article. Intraoperative blood loss was less than 150 ml in all patients. Postoperative period was uneventful with no morbidity or mortality. Discussion Intraoperative bleeding during surgical excision of scalp AVMs can be troublesome and challenging. To combat this, the authors advocate proximal feeding artery temporary clipping prior to surgical excision of the lesion. The external carotid artery was temporarily clipped in one case and superficial temporal artery in two patients. Conclusion Although most SAVMs can be operated by traditional method of excision, use of temporary clipping of feeding arteries (like Superficial temporal artery[STA], External carotid artery[ECA]) enables total excision of giant SAVMs with minimal blood loss for a definitive cure. This novel technique obviates the need for preoperative embolization.

Cirsoid aneurysms (arteriovenous malformations [AVMs]) of the scalp are rarely encountered in neurosurgical practice. Patients with AVM of the scalp present clinically at times with headache and a small innocuous-looking subcutaneous scalp lump or a large, pulsatile mass with or without bruit, which has a propensity to massive hemorrhage. Complex vascular anatomy and interconnections, high shunt flow, and possible cosmetic complications tend to make their management difficult. We report a rare case of young man who presented with progressively enlarging swelling over left fronto-temporo-parietal and occipital region of the scalp since 8 years. Digital subtraction angiography of internal and external carotid vessels revealed high-flow, complex left parietal scalp AVM supplied by multiple tortuous feeders from left superficial temporal artery (STA), left middle meningeal artery, left occipital artery with collateral supply from right occipital artery, and right STA. Drainage into external jugular vein through multiple tortuous frontal, temporal, and occipital scalp veins with venous varix. Being high-flow shunt and because of suspected cosmetic complications, surgical excision was considered.

Gastric cirsoid aneurysm is an arterial malformation found in the submucosa of the stomach. It is a rare, but potentially life-threatening cause of gastrointestinal bleed. We present a case of a 48 year old male who presented to the ER unconscious, unresponsive, pale, and tachycardic. Patient expired and an autopsy was performed. Upon examination blood was found in the GI tract. During examination an arterial malformation was found in the body of the stomach. Histological samples were taken and the findings were consistent with gastric cirsoid aneurysm. Diagnosis can be made through endoscopy, angiography, or red cell scanning. Current treatment is hemostasis achieved by either thermal, regional injection or mechanical therapies. Multiple therapies are found to be more successful than monotherapy. Gastric cirsoid aneurysms are thought to make up

We describe the unique case of a 6-year old boy who presented with recalcitrant generalized tonic-clonic seizures and clinicoradiological features of congenital Cirsoid aneurysm. The lesion was supplied by occipital arteries and a large right parietal parasagittal intracranial feeding artery in a Yokouchi type C pattern. The venous drainage was communicating with the posterior part of the superior sagittal sinus. Six months after successful ligation of the feeding arteries and complete surgical excision of the lesion, the patient remains seizure free.

Background Arteriovenous malformations (AVMs) of the scalp are rare and infrequently encountered by the neurosurgeon. Case Description We report a unique case of a 42-year-old patient who presented with a progressive worsening of visual acuity in the right eye (lower quadrantanopia) and palpebral ptosis. Physical examination revealed a right exophthalmos and a right frontoparietal scalp soft swelling when the patient was in the supine position. Neurologic work-up showed a scalp AVM extending into the orbit and connected to an intraorbital cavernous angioma. The patient was treated with a frontotemporal craniotomy and decompression of the orbit. Conclusions In the rare case of intraorbital extension of a scalp AVM, neurologic symptoms may appear when the size of the vascular malformation increases with age. The aims of surgery should be decompression of the orbit and aesthetic preservation, rather than complete excision. A review of the literature is also provided.

Arteriovenous malformation (AVM) of the scalp is an uncommon entity. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complications. The etiology of scalp AVMs that is, cirsoid aneurysm may be spontaneous or traumatic. Clinical symptoms frequently include pulsatile mass, headache, local pain, tinnitus; and less frequently, hemorrhage and necrosis. Selective angiography is the most common diagnosis method. Surgical excision is especially effective in AVMs and the most frequently used treatment method. Here, we present one such case where staged embolization, excision, and subsequent grafting was done.

Cirsoid aneurysms, also known as scalp arteriovenous malformations (AVM), are rare congenital extracranial vascular anomalies that often present as an enlarging pulsatile scalp mass. A 14-yr-old male presented with a pulsatile scalp lesion that was first noticed 3 yr prior and had progressively enlarged. No history of trauma was reported. MRI demonstrated a 4 cm wide and 2 cm tall nidus and catheter angiography was performed to further define the vascular supply and drainage. The patient underwent transvenous endovascular embolization followed by surgical excision via a bicoronal incision, as shown in this operative video. Care was taken to identify, cauterize, and transect feeding vessels from the superficial temporal, supratrochlear, and supraorbital arteries circumferentially to completely devascularize and resect the galeal nidus from overlying scalp tissue and underlying pericranium. Previously unreported in the literature, transosseous emissary veins partially draining the lesion were noted on angiography and were waxed thoroughly during surgery. Six-month follow-up examination demonstrated a well-healed incision without evidence of AVM recurrence. The unique venous drainage of this cirsoid aneurysm highlights the value of diagnostic angiography to fully characterize these rare and complex vascular lesions prior to pursuing definitive treatment. IRB approval was obtained from the Ann & Robert H. Lurie Children's Hospital of Chicago Institutional Review Board (IRB #2018-1799). The IRB waives the requirement of obtaining informed consent for this study in accordance with 45 CFR 46.116(d).

A female patient with severe pulmonary hypertension was admitted for lung transplant evaluation. As an incidental finding, the chest CT showed diffuse and dilated coronaries, not detected at previous echocardiography. A coronary CT angiography was then performed using a 64-multidetector computed tomography (MDCT) scanner to better evaluate the coronary tree. The images obtained after postprocessing demonstrated tremendously aneurysmatic and tortuous coronary arteries and the presence of a septal branch deepening into the myocardium and penetrating the right ventricle cavity, forming an abnormal arterioventricular fistula. A causal relation between the aneurysms and the fistula is suspected.

venous fistula of the facial artery and vein. H. G. paYTON, FD.5., F.R.CD. (C), R. A. MUSTARD, MD., F.R.CS. (C), F.A.CS., and JAMES SIM, DD.5., Toronto, Ontario, Canada. Oral. Surg. 37:474-9 (1974) The occurrence of aneurysms and arteriovenous fistulas in the vicinity of the oral cavity is discussed. The value of angiography is mentioned. A case of trauma causing a cirsoid aneurysm and an arteriovenous fistula is described. L. R. Manson-Hing

avernous carotid fistulas (CCFs) represent abnormal shunts between the cavernous sinus and its arterial C inflow. The wide heterogeneity of the pathology that underlies CCFs, and their associated clinical severity, has made their evaluation and treatment exceptionally challenging. The earliest attempt to surgically treat a CCF is attributed to Benjamin Travers in 1811, who directly ligated the ipsilateral common carotid artery in a patient suffering from a “cirsoid aneurysm of the orbit” (3). In 1931 Brooks and Gardner used muscle to pack the venous side of direct fistulas through their opening in the carotid artery (3). Such attempts often ultimately required ligation of the ipsilateral common or cervical internal carotid artery (ICA), a technique that was fruitful in only 30% 50% of cases (17). These early attempts to mitigate the effects of CCFs were hampered by inadequate imaging techniques necessary to understand the underlying the disease processes. By 1934, Terry and Mysel (19) were the first to leverage the newly developed technique of cerebral angiography to provide the insight of “pulsating exophthalmos,” efforts that decades later culminated in establishing digital subtraction angiography as the gold standard in imaging CCFs.

A case of Dieulafoy's vascular malformation of the jejunum treated by laparoscopic surgery is described. The patient was a 31-year-old-woman who had complained of melena and had severe anemia needing blood transfusion. Angiography revealed microaneurysms and hypervascularity of the jejunum in the area between the first and second jejunal arterial fields. Laparoscopic partial resection of the jejunum was performed. The resected specimen was histologically diagnosed as Dieulafoy's vascular malformation. Since the operation, the patient has been free of melena and anemia. Small-intestinal Dieulafoy's vascular malformation is rare, as only 41 cases have been reported during the past three decades. Almost two-thirds of the patients were under 40 years old. Most of the patients complained of melena. The lesion was preoperatively identified in 14 of the 41 patients, while angiography was useful to define the lesion. Thirty-six of 37 patients for whom treatment methods were reported were surgically treated. While there are various treatment methods for intestinal bleeding, a surgical operation is often needed. When the disease location is obvious, treatment with laparoscopic surgery can reliably produce good results, in terms of its rate of cure, minimal invasiveness, and better cosmetic effect.

Obscure gastrointestinal bleeding has been defined as bleeding from a source that cannot be readily determined by conventional investigations, such as barium studies and endoscopic investigation. In some series, it can account for up to 5% of all hemorrhages, and the source is often elusive because the culprit lesions are anatomically inaccessible, small, or subtle. Among the causes of obscure gastrointestinal bleeding, Dieulafoy’s lesions are one of the more treacherous and life threatening, because bleeding is often massive and recurrent. Initially described by Gallard in 1884, this cause of bleeding was more accurately characterized later by the French surgeon Georges Dieulafoy in 1896 as the “exulceratio simplex” and subsequently carried his name after he reported three fatal gastric hemorrhages in asymptomatic young men. This abnormality has also been referred to as Dieulafoy’s ulcer, Dieulafoy’s disease, gastric aneurysm, gastric arteriosclerosis, submucosal arterial malformation, cirsoid aneurysm, caliber persistent artery, and solitary exulceratio simplex. It has been described as unrecognized rather than rare, yet its reported incidence as a source of upper gastrointestinal bleeding ranges from 0.3% to 6.7%. Dieulafoy’s disease is found in 1% to 2% of patients undergoing operations for upper gastrointestinal hemorrhage. Unless the proper diagnosis is made, this entity can be associated with a high mortality despite the availability of multiple therapeutic modalities.

Cirsoid aneurysms (arteriovenous fistulas) of the scalp are rare lesions. They are infrequently encountered in neurosurgical practice. These lesions are difficult to manage because of their complex vascular anatomy, high shunt flow and cosmetic disfigurement. We report our experience in the surgical management of these lesions. We treated 11 patients with cirsoid aneurysms surgically. All except one patient were males who were in the second and third decades of life. History of trauma was present in 6 patients. In one patient, the lesion had been present since birth. Occipital and frontal regions were the sites commonly involved. Superficial temporal, occipital and posterior auricular arteries were the most frequent feeding arteries. The size ranged from 3 cms to 12 cms. Following investigations were done: CT, MRI, MRA, angiography and Doppler studies. Excision of the lesion was done in 8 patients and en bloc resection of the lesion with the scalp with reconstruction was done in the remaining three. One among the three patients who underwent en bloc resection had undergone prior surgery. None of the patients underwent preoperative endovascular treatment. One patient had undergone intralesional injection of sclerosing agents twice. Superficial scalp necrosis occurred in two patients but was treated successfully. All the patients except one had good cosmetic results and there was no recurrence during an average follow up of 18 months. Surgical excision with good cosmetic results is feasible in patients with cirsoid aneurysms.

Cirsoid aneurysms are rare arteriovenous malformations (AVM) of the scalp and extremities. They are commonly congenital but post-traumatic cirsoid aneurysms have also been reported. Clinical features include- gradually increasing swelling, pulsatile mass, bruit, headache and tinnitus. Post-traumatic aneurysms of the scalp are uncommon. We report a case with successful surgical excision of scalp AVM.

Uterine arteriovenous malformation (AVM) is a rare condition that has been reported in patients ranging in age between 18 and 72 years1. Several terms have been used for uterine AVM, including arteriovenous fistula, arteriovenous aneurysm, cirsoid aneurysm, racemose aneurysm, pulsatile angioma and cavernous angioma2. Arteriovenous malformations can be congenital or acquired and consist of a ‘proliferation of arterial and venous channels with fistula formation and an admixture of small capillary-like channels’2. Congenital AVM is very rare and is the result of a defect in the embryonic development of vascular structures3,4. Most uterine AVMs are acquired following damage to the uterine tissue. Cases of acquired AVM have been attributed to a variety of causes, including pelvic trauma, surgical interventions such as dilatation and curettage and Cesarean section, cervical and endometrial carcinoma, trophoblastic diseases, inflammation and diethylstilbestrol exposure, and can be idiopathic5–8. Uterine AVMs grow slowly and the appearance of symptoms may be delayed. However, the onset of symptoms can be sudden4. Patients may suffer from irregular vaginal bleeding, heavy menses and/or abdominal pain. Bleeding is thought to occur as a result of vessels of the AVM being exposed by shedding of the endometrium. There are several signs that can indicate the diagnosis of uterine AVM; an audible bruit or palpable thrill may be present and in some cases a pulsatile mass can be detected on manual examination7. A 40-year-old woman (gravida 6, para 3, abortus 3) presented at our hospital with heavy menstrual bleeding. The bleeding was reduced by intravenous administration of 10 IU oxytocin in physiological solution and methylergonovine maleate was then prescribed until bleeding ceased. An ultrasound scan was performed 3 days after this. The patient declined to undergo a transvaginal scan. On transabdominal gray-scale ultrasound, we observed multiple irregular hypoechoic spaces in the anterior wall and fundus of the uterus, which formed a mass that extended to the endometrium Figure 1 Gray-scale transabdominal ultrasound image showing hypoechoic spaces in the anterior wall and fundal part of the uterus extending to the endometrium.

Arteriovenous malformation (AVM) of the scalp is an uncommon entity. Its management is difficult because of its high shunt flow, complex vascular anatomy, and possible cosmetic complications. The etiology of scalp AVMs, i.e., cirsoid aneurysm, may be spontaneous or traumatic. Clinical symptoms frequently include pulsatile mass, headache, local pain, tinnitus, and less frequently, hemorrhage and necrosis. Selective angiography is the most common diagnosis method. Surgical excision is especially effective in AVMs and the most frequently used treatment method. Here, we present one such case where staged embolization, excision, and subsequent grafting was done.

Nonatherosclerotic cerebrovascular arteriopathies share epidemiologic and clinical features, but few studies directly compare histologic features of the intracranial vasculature. We studied 3 adult autopsy cases of fibromuscular dysplasia in patients who died of basilar artery aneurysm rupture, vertebral artery dissection, or Moyamoya syndrome. Fibromuscular dysplasia was only identified when multiple sections (optimally of the entire circle of Willis) were examined by microscopy. A fourth case of a massive subcutaneous scalp cirsoid aneurysm with classic "string-of-beads" gross appearance and microscopic medial hypertrophy was also compatible with fibromuscular dysplasia. Intracranial vascular changes were compared with those in 1 patient with Ehlers-Danlos type IV (vascular type) and in 4 patients with neurofibromatosis I. Distinct histologic features and distributions of cerebral vessel abnormalities were observed in all 3 disorders. Disordered collagen within the muscularis (identified using picrosirius red histochemistry) was confined to fibromuscular dysplasia; fibrocellular smooth muscle intimal proliferation within parenchymal cerebral arteries was confirmed using smooth muscle actin immunohistochemistry in the Moyamoya case; the patient with Ehlers-Danlos type IV showed aneurysm formation and eccentric intimal thickening of circle of Willis vessels but no obvious abnormalities of the muscularis; and neurofibromatosis I cases showed extensive leptomeningeal smaller-caliber arterial disease that particularly affected the spinal cord. Thus, cranial/intracranial artery involvement is not rare in these conditions but requires extensive sampling to identify the range of features.

A 16-year-old girl presented with a progressively increasing pulsatile subcutaneous scalp swelling with linear tortuous structures in the frontoparietal region. A loud bruit was heard on auscultation. General examination and haematological investigations were unremarkable. In suspicion of arteriovenous malformation a CT angiography (CTA) was performed which showed a large vascular mass formed of bunch of dilated and tortuous vessels in the scalp. Feeders from bilateral superficial temporal arteries were identified with venous drainage by superficial scalp veins (figures 1⇓–3). On the basis of clinical and CTA findings a final diagnosis …

We report a case of “Dieulafoy's ulcer” in the ileum presented with massive hemorrhage. A 56-year-old man who had been treated for acute lymphocytic lymphoma suddenly had massive anal bleeding and was admitted to the hospital. The site of bleeding was determined mid-ascending colon by an emergency selective superior angiography at first time, but obvious bleeding point was not identified. So an ascending colostomy was undertaken. Four days later, massive bleeding occurred from the oral side of the colostomy of the ascending colon. Emergency selective angiography showed extravasation of contrast medium in the ileum. A catheter was induced into the mesenteric artery supplying the lesion, and the patient was transferred to the operating room immediately. Dye solution was injected intraoperatively, and a blue-stained segment of the ileum was resected. Histologic examination showed an ileal mucosal ulcer with ruptured arteries in the submucosal layer, compatible with Dieulafoy's ulcer. Such lesion has been called by many terms, including “cirsoid aneurysm”, and these terms are meant the same disease.

A 10-year-old male presented with pain and restriction of movements of left knee for 6 months. A lesion with hyperintensity on T2 weighted images was demonstrated in the anterior aspect of the left knee. Patient was treated with arthroscopic removal of the lesion which later on proved to be cirsoid aneurysm of the synovium. We could not find any other report of a "cirsoid aneurysm" in the synovium of a joint in the English literature. This case is probably the first report of cirsoid aneurysm in the synovium of a joint.

Dieulafoy lesion (DL), also known as Cirsoid aneurysm, and submucosal arterial malformation was originally described by Gallard in 1884. In 1898, the French surgeon, Dieulafoy, reported 3 patients with hematemesis and gastric bleeding emanating from a submucosal vascular anomaly. Although DL is seen most commonly in the gastrointestinal tract, the presence of this lesion in the bronchus has been reported in 12 cases previously. In this report, we present the 13th reported case of hemoptysis resulting from bronchial DL, review the previously reported cases, and comment on the appropriate diagnostic and therapeutic strategy.

Context: Cirsoid aneurysms of scalp are rare lesions which are mainly treated by surgical excision. Endovascular embolization was described either alone or prior to surgery in order to minimize the risk of bleeding. However, the endovascular therapy also carries the risk of scalp necrosis, escape of embolization material to circulation, and recurrence of the lesion. Aim: To evaluate the results of well-planned classic surgical excision of cirsoid aneurysm. Study Design: This is a retrospective case series study. Materials and Methods: This is a retrospective case series study on nine patients with cirsoid aneurysms who were treated with surgical excision. Preoperative Planning for location, size, feeding arteries, and venous drainage of the lesions were done by plain and contrast enhanced CT, MRI, MR angiogram, and selective internal and external carotid angiograms. Complete surgical excision for the lesions was done. Postoperative evaluation of excision was done by cranial magnetic resonance angiography in all the patients. The mean follow up period was 34.1 (±7.62 STD) months. Results: The lesion was located in the occipital region in three (33.3%) cases, frontal region in two (22.2%) cases, temproparietal region in two (22.2%) cases, parietal region in one case (11.1%), and vertex in one case (11.1%). The superficial temporal artery was involved in seven (77.8%) cases, the occipital artery was involved in six (66.7%) cases, the posterior auricular artery was involved in five (55.6%) cases, the supraorbital artery was involved in two (22.2%) cases and the middle meningeal artery was involved in two (22.2%) cases. Total excision of the lesion was achieved in eight patients and en bloc resection and primary closure was done in one patient . Postoperative magnetic resonance angiogram showed no residual lesion in all patients. No postoperative complication related to the surgery had occurred. No recurrence had occurred during the follow-up period (mean 34.1 ± 7.62 STD months). Conclusion: Well-planned surgery of cirsoid aneurysm of the scalp without preoperative interventions could achieve complete excision of the lesion without any residual masses or recurrence and with a low incidence of complications.

Arteriovenous fistulae (AVF) were first described by Hunter in 1757. The outdated term of cirsoid aneurysm was applied to vascular malformations of the scalp in 1833 by Brecht. An AVF is a fistulous connection between the arterial feeding vessels of the scalp and the draining veins, bypassing an intervening capillary bed [6]. Although AVF may be congenital, they are more often acquired due to injury of neighboring vessels [2, 8], including iatrogenic microtraumatisms such as hair transplantation. Among the various existing procedures for baldness, punch autograft technique is one of the preferred for its simplicity, effectiveness, and safety. AVF of the scalp is a very rare complication among all procedures of hair restoration done each year in the world, since about 40 years. Suspected clinical diagnosis was easily made but further vascular investigations, especially computed tomography angiography (CTA), were helpful for diagnosis confirmation of this rare pathology and to plan the treatment. Case Report

Uterine cirsoid aneurysm is uncommon. It is important to make a diagnosis of this disease preoperatively, because repeated curettages may induce life-threatening massive genital bleeding. We present a case of a 51-year-old woman with uterine cirsoid aneurysm in whom MRI and MRA were very useful for the preoperative diagnosis. The radiologic appearances on ultrasonography, CT, conventional SE MRI, MRA, dynamic MRI, and pelvic angiography are presented. Conventional SE T1-weighted and T2-weighted images demonstrated multiple flow voids in the uterus and bilateral adnexal regions. MRA demonstrated a cluster of distinct, tortuous, and coiled vascular channels in the pelvis. MRA could obtain images almost equal to angiography and was considered to be an excellent noninvasive imaging technique for the diagnosis of uterine cirsoid aneurysm.

Objective:We report an interesting case of a right temporal pre-auricular arteriovenous fistula (cirsoid aneurysm) causing intractable tinnitus successfully managed by transarterial n-butyl cyanoacrylate glue embolisation.Case report:A 52-year-old female presented with a one-year history of tinnitus and pulsatile swelling in the right pre-auricular region. A colour Doppler ultrasound test and magnetic resonance angiography revealed a high-flow scalp arteriovenous fistula with a feeder vessel from the distal superficial temporal artery, which drained into the corresponding, dilated, tortuous vein. The patient underwent diagnostic digital subtraction angiography. This was followed by transarterial embolisation of the fistula using a 50 per cent mixture of n-butyl cyanoacrylate glue and Lipiodol®, with manual distal venous occlusion. A successful outcome was achieved with instant relief of symptoms.Conclusion:Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding.

Cirsoid aneurysms of the scalp are a rare abnormality with severe cosmetic deformity and possibly of severe hemorrhage. They present as a diagnostic and management challenge, but evaluation with multidetector computed tomography is useful in the diagnosis and treatment planning of these clinically complex disorders of the extracranial circulation. We present a case report of a 38-year-old New Caledonian male who had a large pulsatile mass in his scalp, which had progressively increased in size since the age of 17 years. The clinical and imaging features are outlined, in addition to treatment and prognosis.

Evaluation of management strategies for scalp arterio-venous malformation (AVM).A retrospective analysis of data of 31 patients with scalp AVM was carried out at all India Institute of medical sciences New Delhi between 1997 and 2010. All the patients except one underwent digital substraction angiography. Depending upon the size of AVM, we classified them in to three groups. Group 1 (small) size up to 4.9 cm, group 2 (medium) size 5-9.9 cm and group 3 (large) size more than 10 cm. Patients in group 1 and 2 underwent direct excision. Patients in group 3 underwent pre-operative embolization followed by surgical excision. Five patients refused any treatment. Patients were analysed to look into results, complications and recurrence in follow up.There were 11 patients in group 1, 12 in group 2 and 8 in group 3. There were 18 males and 13 females with mean age of 25 years ranging from 13 to 55 years. The mean duration of symptom was 7.2 years. Angiography was performed in 30 patients. Superficial temporal artery (80.6%) was the most commonly involved. 18 patients underwent direct excision, 6 underwent embolization followed by excision and 2 underwent embolization. One patient in surgery group and two patients in embolization group had recurrence. One patient expired due to complications of hypotensive shock secondary to exsanguinating haemorrhage from AVM.Surgical excision has excellent outcome in treatment of scalp AVM. Pre-operative embolization reduces vascularity and helps in easy identification of AVM during surgery thus achieving complete excision. The size of AVM has no correlation with the number of feeding vessels. There are high chances of recurrence in large AVM after embolization.

Cirsoid aneurysm, an uncommon abnormal either congenital or acquired arteriovenous communication, is described. As massive life-threatening bleeding can be a consequence, diagnosis is very important. Earlier, angiography was the only imaging method available for visualizing vascular lesions and recent developments in imaging techniques have made diagnostic imaging of cirsoid aneurysms possible using ultrasonography, color flow mapping, magnetic resonance imaging and magnetic resonance angiography. In this report, a patient with intrapelvic cirsoid aneurysm posthysterectomy who died 8 h after she had been kicked in the abdomen is described and the results obtained by various imaging techniques are discussed.

Cirsoid aneurysms are rare arteriovenous malformations of the scalp, which are usually of congenital etiology. We describe the case of a young Sri Lankan farmer who presented with a progressively enlarging scalp mass of interesting character, yielding unique images on plain radiography before more advanced imaging and subsequent definitive treatment were performed. The utility of this simple imaging technique in underdeveloped settings is highlighted, and further diagnostic and treatment options are discussed in brief.

Scalp arteriovenous fistulas (AVFs) are rare and potentially complex lesions that can be treated in a multimodal fashion. We present here the first successful treatment of a Stage Ib scalp AVF using a balloon-protected, retrograde transvenous embolization with the liquid embolic Onyx.We describe the case of a 60-year-old man with a scalp AVF that had a fine, diffuse, serpiginous arterial supply, precluding a transarterial approach, and multiple venous drainage paths, including the external jugular vein (EJV). The lesion was successfully embolized exclusively via a femoral transvenous retrograde approach using Onyx with balloon-protection of the EJV to simultaneously prevent pulmonary embolism and enable improved retrograde casting of the fistula-outflow zone.The combined use of Onyx with proximal balloon-protection in a transvenous retrograde femoral approach is a novel method that can be used to definitively treat scalp AVFs with a defined catheter-accessible venous outflow.This technique may be useful when transarterial embolization, direct puncture, or surgical excision are not practical or possible.