Combined endovascular and surgical management of scalp cirsoid aneurysms: A case series from Northeast India

Objective: Cirsoid aneurysms are rare, high-flow extracranial arteriovenous malformations of the scalp characterized by complex vascular anatomy and significant arteriovenous shunting. Owing to their rarity, optimal management strategies remain poorly defined. This study aims to describe the clinical presentation and evaluate outcomes following a combined endovascular and surgical approach. Methods: This retrospective consecutive case series included all patients treated for scalp cirsoid aneurysms between October 2022 and December 2023 at a tertiary neurosurgical center. All patients underwent detailed radiological evaluation, including computed tomography angiography and digital subtraction angiography (DSA). Demographic characteristics, clinical features, treatment details, and outcomes were analyzed. Results: Six patients (4 males, 2 females) with a mean age of 23.5 years (range: 18-30 years) were included. All presented with painless pulsatile scalp swelling. DSA demonstrated high-flow lesions supplied by branches of the external carotid artery, most commonly the superficial temporal artery, without intracranial communication. All patients underwent preoperative embolization using Onyx™ 18 (Medtronic, Minneapolis, MN, USA), followed by complete surgical excision within 24-48 hours. Complete obliteration was achieved in all cases, with no perioperative complications. No residual arteriovenous shunting or recurrence was observed during follow-up. Conclusions: In this small retrospective series, preoperative Onyx embolization followed by surgical excision was associated with complete lesion obliteration, favorable clinical outcomes, and absence of recurrence during follow-up. Larger studies are required to confirm long-term efficacy and durability.