Medusa’s Wrath: Bleeding Giant Scalp Arteriovenous Malformation in an Adult: A Case Report

Abstract

Background Scalp arteriovenous malformation (AVM) is a rare congenital disease that may present with massive bleeding. To date, surgical excision remains the definitive management. However, the procedure could lead to intraoperative bleeding due to the tumor’s high blood flow and complex vascularity. Case Report A 49-year old Filipino male presented with a bleeding giant scalp AVM. Computed tomographic scan and duplex studies showed multiple feeding vessels with turbulent flow arising primarily from the right superficial temporal, right posterior auricular, and occipital vessels. Prior to surgery, the patient underwent transfusion due to preoperative hemoglobin of 6 g/dL. Proximal control of the right external carotid artery was performed through a supine position and left in place to reduce the majority of blood flow to the AVM. The patient was turned to a prone position for surgical planning to achieve maximal skin-sparing dissection prior to excision. First, ligation of bilateral superficial temporal and posterior auricular arteries was performed. Next, excision above the periosteum with segmental ligation of feeding vessels around the AVM was carried out. Reconstruction of the defect was done via scalp advancement flap and split-thickness skin grafting. Intraoperative blood loss was 1.6 L. On the sixth postoperative day, the patient was discharged with 100% graft take. Conclusion Management of scalp AV malformation is challenging, and despite measures to decrease intraoperative bleeding, blood loss is still high. While preoperative embolization has been reported to decrease the risk of bleeding, this procedure is not currently available in our setting. Our case highlights the complexity of giant scalp AV malformation management in a limited-resource setting. Even in the absence of endovascular intervention, outright surgical excision of AVM can be performed, albeit with higher levels of blood loss.

A Rare Case of Scalp Arteriovenous Malformation in an Adolescent Patient

“…The most recently published case report of scalp AVM by Briones et al featured a 49-year-old man who presented to the ER with a giant AVM of the right temporal area accompanied by a large amount of bleeding [ 10 ]. The preoperative hemoglobin concentration was 6 g/dL which required a preoperative blood transfusion.…”

“…Because of the differences in high shunt flow, vascular anatomy, and cosmetic deformities, treatment strategies have been documented to be case-dependent, including surgical excision, ligation, or endovascular embolization [2]. Several studies demonstrated different presentations, diagnostic methods, and management options [10,[12][13][14]. However, scalp AVMs remain a rare entity in need of further neurosurgical focus.…”

“…Patients usually present complaining of an enlarging, pulsatile mass, headaches, and tinnitus [ 8 , 9 ]. They can also present with bleeding largely affecting preoperative hemoglobin concentration and requiring preoperative blood transfusion [ 10 ].…”