Intramuscular Haemangioma of the Forearm

The Challenges of Upper Extremity Intramuscular Hemangioma: a Case Study and Systematic Review

BACKGROUND

Intramuscular hemangiomas (IMHs) are rare, benign vascular tumors, comprising 0.8% of all hemangiomas. Upper extremity (UE) IMHs pose diagnostic and therapeutic challenges given their rarity, invasive nature, and potential for neurovascular involvement. We report a comprehensive systematic review of UE IMH management and a challenging case report.

METHODS

A systematic review was performed using PRISMA guidelines. Electronic databases were used to identify papers describing UE IMHs through 2019. Patient demographics, clinical presentation, management, complications, and outcomes were reviewed. Based on operative timing, cases were categorized as either "primary" (excision performed at initial diagnosis) or "secondary" (excision performed after failure of conservative treatment).

RESULTS

Eighteen articles encompassing 25 patients were included in our systematic review. Of those, 18 underwent primary excision and 7 underwent secondary excision. The majority involved the forearm or antecubital region. Complete excision, evaluated by gross examination or pathology, was reported in all primary cases and 71% secondary cases. Primary excisions demonstrated smaller mass size (19.4cm2 versus 165.3cm2) and superior reported functional outcomes (100% versus 33%). Complications were reported in 5% of the primary excisions compared to 71% of the secondary excisions, where 1 complication was a fatal hematoma.

CONCLUSION

The literature concerning UE IMH is limited to mostly case reports and several case series with the potential risk of bias. With careful dissection and microsurgical technique, wide local excision followed by complete reconstruction can be successfully performed at initial diagnosis for UE IMHs. At early stages, smaller lesion size significantly reduces the risk of functional impairment and complications.

Intramuscular thrombosed arteriovenous hemangioma of the upper right arm mimicking a neuroma of the ulnar nerve: case report

OBJECTIVE AND IMPORTANCE

Soft tissue arteriovenous hemangiomas (AHs) are benign vascular hamartomas characterized by the presence of arteriovenous shunts. Few cases of soft tissue AHs have been found in the literature, and these were frequently described as cutaneous lesions of the limb or of the scalp. Intramuscular AHs are extremely rare. AHs are prevalent in children and women and are often associated with other types of malformations or genetic disorders. We present the case of an elderly woman with an intramuscular thrombosed AH on the volar side of the upper right arm. Owing to the close proximity of the ulnar nerve, this lesion was initially identified as a neuroma.

CLINICAL PRESENTATION

A 70-year-old woman presented with a short history (a few months) of progressive growth of a nonpulsating, solid, palpable mass deeply localized in the distal third of the right upper arm. At the neurological examination, local evoked pain was the only sign detected. A Doppler ultrasound examination depicted a hyperechoic spherical lesion with widespread calcium deposits and necrosis.

INTERVENTION

The exploration of the upper arm revealed a capsulated nodular lesion, 7 cm in diameter, that morphologically corresponded to a thrombosed vascular lesion. This lesion was removed en bloc, and an unequivocal connection with a muscular branch of the ulnar artery was detected. The histological analysis revealed AH.

CONCLUSION

Intramuscular AHs are rare and may easily be misdiagnosed as neuromas, especially when they are contiguous to a peripheral nerve.