Management of a scalp arteriovenous malformation in a lower-middle income country: A case report.

Spontaneous scalp arteriovenous malformations (AVMs) are often present at birth but are usually noticed when they cause aesthetic problems in adulthood. Concerning treatment; there has been a shift towards endovascular treatment alone or in combination with surgical resection. In developing countries, endovascular options might not be readily available. We hereby report a case of a large spontaneous scalp AVM managed successfully via surgical excision only. A 35-year-old man presented with a large pulsating mass located in the occipital region of the scalp. This mass had been present from birth and had been growing over the years. Computed tomography (CT) scan and CT-angiography showed an occipital, contrast-enhancing mass, mostly lateralized to the right and fed by the right occipital artery. The patient did not benefit from digital subtraction angiography or pre-operative embolization. An indication for surgical excision was made. The first step was geared at controlling hemorrhage which was only partially effective due to another feeder that was missed on the CT-angiography. The second step involved dissecting and de-vascularizing the lesion. Complete excision of the AVM was achieved along with excision of the adjacent galea. Management of large scalp AVMs is possible even in resource strained environments. Knowledge of the behavior of feeders regarding lateral or midline disease, coupled with meticulous interpretation of available imaging, is essential in planning surgery. Intra- operative bleeding can be controlled by early temporary clipping or ligation of the main feeders and then one can proceed with the surgical resection.