The term "vascular anomaly" encompasses a broad spectrum of congenital malformations and tumors of vascular origin, ranging from minor birthmarks to life-threatening and severely disfiguring conditions. Vascular abnormalities include a diverse group of vessel disorders that can affect any part of the vascular system, including the lymphatic vessels, capillaries, veins, and arteries. Each type of abnormality possesses distinct anatomy, pathophysiology, clinical behavior, and requires a specific therapeutic approach [10-13].

Arteriovenous Malformations (AVMs) are high-flow lesions formed by abnormal connections between arteries and veins, bypassing the capillary bed and creating a shunt. Unlike hemangiomas, AVMs exhibit ectasia of abnormal blood vessels lined by flat endothelial cells, rather than endothelial cell proliferation. AVMs result from errors in blood vessel formation during embryogenesis.

Rapid growth of AVMs can be triggered by factors such as trauma, puberty, pregnancy, or hormonal changes. This growth is due to local hemodynamic changes in blood pressure and flow, vessel dilation, and collateral vessel formation, rather than cellular proliferation.

AVMs are chronic, progressive, and potentially fatal, often leading to massive blood loss. They frequently recur after inadequate resection. Extracranial AVMs typically manifest in the cheek, lips, neck, scalp, ear, tongue, and mandible. In patients over 40 years of age, newly developed lesions in previously unaffected areas are often associated with a history of trauma. At this advanced stage, AVMs present with severe symptoms such as bleeding, pain, tissue loss, and ulcer formation. Our patient, a 36-year-old woman, had a history of trauma at the time of presentation.

Clinically, early AVM lesions may present with an overlying vascular blush in the skin. The underlying tissue is typically thicker, non-fluctuant, and non-compressible but pulsatile. When mucosa is involved, it is often thickened and vascular. More advanced lesions may show clearly dilated vessels on the surface and beneath, as well as pulsation. AVMs can infiltrate the skin, leading to ulcerations and bleeding. These characteristics partially aligned with our findings of a painless, pulsatile lesion with swollen vessels [14-17].

Radiographic imaging is essential in the diagnosis and operative planning of arteriovenous malformations (AVMs), utilizing techniques such as ultrasound with color Doppler, contrast-enhanced CT scans, and magnetic resonance imaging (MRI) with angiography. While ultrasound effectively demonstrates high-flow lesions, it may not accurately determine the full extent of the lesion, particularly with deeper involvement. MRI, however, is particularly valuable for assessing the involvement of adjacent soft tissues, with the lesion typically appearing as voids in both T1-weighted and T2-weighted sequences.

The management of AVMs centers on the obliteration of the nidus, the network believed to be responsible for recruiting new blood vessels that contribute to the lesion’s growth. Intra-arterial embolization, which involves occluding the feeder blood vessels, reduces blood flow to the lesion and may induce tumor necrosis. This procedure can be performed as an emergency intervention in cases of massive bleeding or preoperatively to prevent hemorrhage during surgical resection. However, embolization alone is not considered a definitive treatment, as it can lead to ulceration, necrosis, and ischemic changes in the lesion. Therefore, surgical resection is often necessary as an adjunct treatment, especially in high-flow lesions where the lesion may increase in size and cause ischemic pain, ulceration, or bleeding.

In this case, embolization was avoided due to the lesion’s accessibility, while ligation of the feeder artery was feasible. The decision to proceed with complete resection of the lesion after ligating the feeder arteries was influenced by the lesion’s size (4x3 cm), its superficial location, and the absence of neurological deficits. Patient compliance and financial considerations were also taken into account in formulating the treatment plan [18,19].

Although involvement of the oral cavity is common, it often requires innovative management strategies. Depending on their size and location, "problematic" hemangiomas or vascular malformations can significantly impact both function and aesthetics. Bleeding, pain, and disability are also frequent concerns. Therefore, a thorough understanding of the natural history of vascular anomalies is crucial for those who diagnose and treat these conditions.

We found few case reports of AVMs which are associated with Head and Neck regions.