====== Scalp cirsoid aneurysm treatment ======

The treatment of sAVF is difficult, and many therapeutic approaches have been proposed. General approaches for the treatment of sAVF include ligation of the feeding arteries, surgical removal, electrothrombosis, embolization, and a combination of these approaches.

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. 

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 technique obviates the need for preoperative embolization
((Gangadharaswamy SB, Maulyavantham Nagaraj N, Pai BS. Surgical management of
scalp arteriovenous malformations using a novel surgical technique-Case series.
Int J Surg Case Rep. 2017 Jul 8;37:250-253. doi: 10.1016/j.ijscr.2017.06.057.
[Epub ahead of print] PubMed PMID: 28715722.
)).

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In a [[systematic review]], a total of 58.5% of cases [[scalp cirsoid aneurysm]] were managed with surgical [[excision]] only, 21.6% with endovascular [[embolization]] only, and 14.5% with a combination of both methods. 
((Sofela A, Osunronbi T, Hettige S. Scalp Cirsoid Aneurysms: Case Illustration
and Systematic Review of Literature. Neurosurgery. 2020 Feb 1;86(2):E98-E107.
doi: 10.1093/neuros/nyz303. Erratum in: Neurosurgery. 2019 Dec 1;85(6):861.
PubMed PMID: 31384940.
)).
----
The commonest artery involved in the [[scalp cirsoid aneurysm]] is the [[superficial temporal artery]], due to its long and twisted course. The different methods of treatment include 'en bloc' resection and primary closure of the lesion, and sclerotherapy in which sodium tetradecyl sulfate is injected into the unwanted vessels with carbon dioxide gas, and the vessel is made to undergo sclerosis. The latter is associated with complications such as [[thromboembolism]], [[allergy]] and skin necrosis. Direct puncture endovascular embolization, using either chemical NBCA, absolute alcohol or mechanical coils, is another effective method widely used for AVM correction and an old method of ligation of feeding arteries, which is associated with the formation of collaterals and recurrence
((Elkin DC. Cirsoid aneurysm of the scalp with the report of an
advanced case. Ann Surg 1924; 80:332-40.)).
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Heiferman published a case of a patient who underwent transvenous endovascular embolization followed by surgical excision via a bicoronal incision, as shown in a 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 was noted on angiography and were waxed thoroughly during surgery
((Heiferman DM, Syed HR, Li D, Rothstein BD, Shaibani A, Tomita T. Resection of 
an Embolized Cirsoid Aneurysm With Intracranial Venous Drainage: 2-Dimensional
Operative Video. Oper Neurosurg (Hagerstown). 2019 Mar 1;16(3):E94. doi:
10.1093/ons/opy303. PubMed PMID: 30295882.
)).
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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
((Gangadharaswamy SB, Maulyavantham Nagaraj N, Pai BS. Surgical management of
scalp arteriovenous malformations using a novel surgical technique-Case series.
Int J Surg Case Rep. 2017;37:250-253. doi: 10.1016/j.ijscr.2017.06.057. Epub 2017
Jul 8. PubMed PMID: 28715722; PubMed Central PMCID: PMC5514622.
)).
----
Munakomi et al. presented one case where staged embolization, excision, and subsequent grafting was done
((Munakomi S, Bhattarai B, Cherian I. Conquering the odds: Cirsoid aneurysm with
holocranial feeders-staged embolization, excision and grafting. Asian J
Neurosurg. 2015 Jul-Sep;10(3):259-61. doi: 10.4103/1793-5482.161167. PubMed PMID:
26396624; PubMed Central PMCID: PMC4553749.
)).
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Percutaneous injection of sotradecol can be considered as one of the treatment options for arteriovenous fistula of the scalp. Further experience is needed to compare the safety and effectiveness of sotradecol with other agents currently used in the treatment of scalp arteriovenous fistulae
((Hendrix LE, Meyer GA, Erickson SJ. Cirsoid aneurysm treatment by percutaneous
injection of sodium tetradecyl sulfate. Surg Neurol. 1996 Dec;46(6):557-60;
discussion 560-1. PubMed PMID: 8956889.)).
----
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
((Kumar A, Ahuja CK, Khandelwal N, Bakshi JB. Cirsoid aneurysm of the right
pre-auricular region: an unusual cause of tinnitus managed by endovascular glue
embolisation. J Laryngol Otol. 2012 Sep;126(9):923-7. doi:
10.1017/S0022215112001466. Epub 2012 Jul 5. PubMed PMID: 22874530.
)).
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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
((El Shazly AA, Saoud KM. Results of surgical excision of cirsoid aneurysm of
the scalp without preoperative interventions. Asian J Neurosurg. 2012
Oct;7(4):191-6. doi: 10.4103/1793-5482.106651. PubMed PMID: 23559986; PubMed
Central PMCID: PMC3613641.)).
((Chowdhury FH, Haque MR, Kawsar KA, Sarker MH, Momtazul Haque AF. Surgical
management of scalp arterio-venous malformation and scalp venous malformation: An
experience of eleven cases. Indian J Plast Surg. 2013 Jan;46(1):98-107. doi:
10.4103/0970-0358.113723. PubMed PMID: 23960313; PubMed Central PMCID:
PMC3745130.)).

===== References =====