A radiological classification system for intraneural vascular anomalies: assessment of potential for resection with high-resolution MRI

The diagnostic value of ultrasonography in evaluation of the intraneural vascular anomalies of peripheral nerves

BACKGROUND

The imaging diagnosis of intraneural vascular anomalies of peripheral nerves mostly depended on magnetic resonance imaging (MRI), whereas high-frequency ultrasonography evaluation of intraneural vascular anomalies has been seldom done.

PURPOSE

To evaluate the diagnostic value of ultrasonography in the diagnosis of intraneural vascular anomalies of peripheral nerves.

MATERIAL AND METHODS

A total of 69 consecutive patients seen at Shandong Provincial Hospital Affiliated to Shandong First Medical University between February 2013 and June 2022, each with a clinical suspicion of intraneural vascular anomaly, were included. The ultrasonographic images of intraneural vascular anomalies of peripheral nerves were analyzed and the ultrasonographic features were summarized. These data were compared with MRI, which served as the gold standard for the diagnosis of intraneural vascular anomalies. The kappa statistic was adopted to determine the level of agreement. The sensitivity, specificity, positive and negative predictive values, accuracy, and Youden index of high-frequency ultrasonography as a diagnostic tool were assessed.

RESULTS

Ultrasonography findings were positive in 20 of 69 patients with a clinical suspicion of intraneural vascular anomaly. The diagnosis was confirmed by MRI in 21 patients. There was one false-positive result and two false-negative results by ultrasonography. The κ value was 0.896. The sensitivity, specificity, positive and negative predictive values, accuracy, and Youden index of ultrasonography were 90.5%, 97.9%, 95%, 95.9%, 95.7%, and 0.884, respectively.

CONCLUSION

Ultrasonography could be an accurate, reliable, and convenient imaging tool for the diagnosis of intraneural vascular anomalies of peripheral nerves.

Beyond schwannomas and neurofibromas: a radiological and histopathological review of lesser-known benign lesions that arise in association with peripheral nerves

Peripheral nerve sheath tumors comprise a significant percentage of both benign and malignant soft tissue tumors. The vast majority of these lesions are schwannomas and neurofibromas, which most radiologists are familiar with including the well-described multimodality imaging features. However, numerous additional often under-recognized benign entities associated with nerves exist. These rarer entities are becoming increasingly encountered with the proliferation of cross-sectional imaging, particularly magnetic resonance imaging (MRI). It is important for the radiologist to have a basic understanding of these entities as many have near-pathognomonic MR imaging features as well as specific clinical presentations that when interpreted in concert, often allows for a limited differential or single best diagnosis. The ability to provide a prospective, pre-intervention diagnosis based solely on imaging and clinical presentation is crucial as several of these entities are "do not touch" lesions, for which even a biopsy may have deleterious consequences. To our knowledge, the majority of these benign entities associated with nerves have only been described in scattered case reports or small case series. Therefore, the aim of this article is to provide a radiopathologic comprehensive review of these benign entities that arise in association with nerves with a focus on characteristic MRI features, unique histopathologic findings, and entity specific clinical exam findings/presentation.

Chronic excruciating forearm pain in a child with intra-neural hemangioma: A challenging case report

INTRODUCTION AND IMPORTANCE

Cavernous hemangioma is a rare form of hemangioma. It usually arises in the central nervous system, but the tumor has also been reported in the liver, retina and skin with a lower prevalence. Its occurrence into the peripheral nerves has only been reported a few times. Herein, we report an extremely rare case of intra-neural hemangioma in the ulnar nerve and discuss the complications we faced following surgery.

CASE PRESENTATION

We present a 6-year-old boy with history of severe progressive left forearm pain in the last two years. Imaging studies revealed a soft tissue mass and histopathological exam was in favor of a cavernous hemangioma. Patient underwent surgery to excise the tumor. Despite temporary response, he began to experience excruciating pain shortly after surgery which caused him to adopt bizarre postures.

CLINICAL DISCUSSION

In the more common form of nerve involvement in a hemangioma, the nerve is displaced and surrounded by the tumor. However, in cases with intra-neural involvement, the nerve would have to be sacrificed. This case report brings some rare but important characteristics of a hemangioma in to attention, such as the intra-neural location, possibility of recurrence and aggravating pain with bizarre positions as a result.

CONCLUSION

In cases of intra-neural hemangioma, there is a chance that the patient experiences recurrence and/or excruciating pain following surgery. The orthopedic surgeon should be prepared for the possibility of nerve transfer, repeat surgeries and the need for prolonged palliative pain suppression modalities in the approach to intra-neural hemangioma.

MR imaging of venous malformations: sciatic nerve infiltration patterns and involved muscle groups

The aim of this retrospective cross-sectional study was to provide an MRI-based examination framework of venous malformations (VMs) infiltrating the sciatic nerve and determine the frequency of nerve infiltration patterns and muscle involvement in correlation to the patients’ quality of life. Pelvic and lower limb MR images of 378 patients with vascular malformations were examined retrospectively. Pain levels and restriction of motion were evaluated with a questionnaire. Cross-sectional areas of affected nerves were compared at standardized anatomical landmarks. Intraneural infiltration patterns and involvement of muscles surrounding the sciatic nerve were documented. Sciatic nerve infiltration occurred in 23/299 patients (7.7%) with VM. In all cases (23/23; 100%), gluteal or hamstring muscles surrounding the nerve were affected by the VM. Infiltrated nerves were enlarged and showed signal alterations (T2-hyperintensity) compared to the unaffected side. Enlarged nerve cross-sectional areas were associated with elevated pain levels. Three nerve infiltration patterns were observed: subepineurial (12/23; 52.2%), subparaneurial (6/23; 26.1%) and combined (5/23; 21.7%) infiltration. This study provides a clinically relevant assessment for sciatic nerve infiltration patterns and muscle involvement of VMs, while suggesting that VMs in gluteal and hamstring muscles require closer investigation of the sciatic nerve by the radiologist.

Perineurial Vascular Hamartoma

Perineural vascular proliferations are extremely rare, and only a few cases have been reported in the literature, usually under the designation of "intraneural hemangioma." We report a case of a 28-year-old man with a nodule in the right palm of his hand that developed over an 8- to- 12-month period. Microscopic examination revealed a vascular proliferation growing within connective tissue and entrapping small nerve bundles. The features of the lesion are consistent with an unusual hamartomatous growth of small vessels and nerves rather than a hemangioma arising within a nerve. Clinical and histological details, and a discussion of the relevant literature on this unusual lesion, are provided.